A Map of Healthcare Needs for Mazowieckie Voivodeship

CATCHING GAPS WITH HEALTHCARE MAPS CARDIOLOGY AND ONCOLOGY

A Map of Healthcare Needs for Mazowieckie Voivodeship – Oncology

1 CATCHING GAPS WITH HEALTHCARE MAPS CARDIOLOGY AND ONCOLOGY

Table of Contents

Demographic and Epidemiological Aspects ...... 3 1.1 Population Breakdown ...... 4 1.2 Demographics of counties (powiaty) ...... 9 1.3 Deaths due to cancers ...... 13 1.4 Hospital morbidity rate ...... 27 1.5 Cancer Incidence ...... 33 1.5.1 Distribution of new cases in Poland ...... 34 1.5.2 Distribution of new cases in the voivoideship ...... 54 Status and Use of Resources: the Analysis ...... 80 2.1 Hospitalisation ...... 81 2.1.1 Healthcare providers in Poland ...... 81 2.1.2 Healthcare providers in the voivoideship ...... 86 2.1.3 Analysis of selected healtcare service providers ...... 93 2.1.4 Surgical and Conservative Treatment Analysis ...... 122 2.1.5 Chemotherapy Services Analysis ...... 133 2.1.6 Radiotherapy Services Analysis ...... 144 2.1.7 Hospitalisation – minor up to 18 years of age ...... 158 2.2 Specialist Outpatient Care ...... 163 2.3 Positron Emission Tomography (PET) ...... 170 2.4 Primary Care (POZ) ...... 171 2.5 Medical Staff ...... 174 Healthcare Needs Forecasts ...... 192 3.1 Projected Population Breakdown ...... 193 3.2 Projected demographics of counties (poviats) ...... 199 3.3 Epidemiology Forecast ...... 223 3.3.1 Incidence Forecast ...... 223 3.3.2 5-Year Prevalence Forecast ...... 248 3.4 Services Forecast ...... 252 3.4.1 Surgery Services Forecast ...... 252 3.4.2 Positron Emission Tomography Treatment Forecast ...... 255 3.4.3 Chemotherapy Services Forecast ...... 256 3.4.4 Radiotherapy Services Forecast ...... 259

2 CATCHING GAPS WITH HEALTHCARE MAPS CARDIOLOGY AND ONCOLOGY

Part I Demographic and Epidemiological Aspects

3 1.1 Population Breakdown

Mazowieckie Voivodeship had over 5.3 million inhabitants in 2014, which accounted for approx. 13.9% of the country's population (all data on the population figures in this chapter are as of 31 December 2014). It was the largest Polish region in terms of population (Figure 1).

Figure 1: Population in Poland by voivodeship (2014)

Population number (inPopulation millions) number

Share of people (right axis)

Source: compiled based on data provided by the Central Statistical Office

The population of Mazowieckie Voivodeship was, in demographic sense, older than the population of Poland in general. In 2014, there were almost 843,000 people aged at least 65, which accounted for 15.8% of the total population (Figure 3). This share was higher than the Poland's total (15.3%). The youngest (up to 19 years of age), in turn, constituted approx. 1.1 million, and their share amounted to 20.6% (more by 0.3 percentage points than for the Poland's total). The population aged 20-64 constituted 3.4 million people, accounting for 63.6% of the total population, which share was slightly lower than for the Poland's total (Figure 3).

4 Figure 2: Population structure according to sex and age for Mazowieckie Voivodeship (2014)

Age Men (in thousands) Women (in thousands) group

Surplus of men over women (in thousands) Surplus of women over men (in thousands)

Source: compiled based on data provided by the Central Statistical Office

Figure 3: Population breakdown according to age group in Mazowieckie Voivodeship and in Poland (2014)

Difference in relation to the breakdown of Poland: Greater share in the voivodeship Greater share in Poland

Source: compiled based on data provided by the Central Statistical Office

Analysis of the breakdown of the population by sex and age show numerical that the number of men is greater than that of women in the age group up to 29 years of age, while in the other age groups there are more women than men (Figure 2). The differences in the size of the population of women and men are the largest among the elderly (over 60 years of age) and they increase with age. This is related to the so-called excess mortality of men manifested in the shorter life expectancy of men (cf. Figure 2, Figure 4).

5 Figure 4: Population breakdown by sex and age in Mazowieckie Voivodeship and in Poland (2014)

M W M W M W M W M W M W M W M W M W M W

Source: compiled based on data provided by the Central Statistical Office

Mazowieckie Voivodeship has the slightly longer life expectancy of a newborn than the figures observed for the Poland's total (Figure 5). In 2014, this parameter oscillated at 74 years for boys and 81.8 years for girls. Importantly, this parameter was in both cases greater by 0.2 years compared to the corresponding figures for the Poland's total. The voivodeship ranked 7th in terms of the life expectancy of a newborn recorded for men and 6th place for women (shown from the highest to the lowest values of this measure). The situation is somewhat different in terms of life expectancy of people who turned 60: e60 for men amounted to 19.4 years, and to 24.4 years for women. The values of this parameter are higher than for the Poland's total for men (by 0.3 year) and lower for women (by 0.1 year). The region ranked third in terms of men and 6th in terms of women. Figure 6).

6 Figure 5: Life expectancy of a newborn by voivodeship (2014)

Years M

Source: compiled based on data provided by the Central Statistical Office

Figure 6: Life expectancy of a 60-year-old person by voivodeship (2014)

s Year

W M

Years

Source: compiled based on data provided by the Central Statistical Office

7 In 2014, over 57,000 children were born in Mazowieckie Voivodeship, and the fertility rate1 exceeded 44 children per one thousand women of childbearing age, making the voivodeship first in Poland (in descending order of this index). This result exceeds the national figure by nearly 4 children per one thousand women of childbearing age (Figure 7).

Figure 7: Fertility rate and the number of live births by voivodeship (2014)

Thousands Births per one thousand women aged 15 Birthsper aged thousand women one

Difference versus average value for Poland: Number of births (right axis) Higher average value in Poland Higher value in the voivodeship

In 2014, the population density in Mazowieckie Voivodeship was 150 people per km2, so that the Voivodeship ranked third in terms of this index (in descending order) (Figure 8).

Figure 8: Population density by voivodeship (2014)

Population per 1km2

Source: compiled based on data provided by the Central Statistical Office

1The fertility rate is the number of live births per 1,000 women of childbearing age, i.e. 15-49 years of age.

8 population in 2014: over 1.7 million people, 1.2 Demographics of counties which accounted for 33% of the population (powiaty) of Mazowieckie Voivodeship. The Łosice 5 cities having county rights and 37 county ranked last in terms of population counties were identified in the Mazowieckie (32,000) in 2014, a mere 0.6% of the Voivodeship in line with the administrative population of Mazowieckie Voivodeship division. The city of Warsaw had the largest (Figure 9).

Figure 9: Population in the counties of Mazowieckie Voivodeship (2014)

Population number (in thousands) (in number Population

Share of the total population (right axis)

The results of the analysis of the population structure by sex and age in some of the counties of Mazowieckie Voivodeship are similar to those described for the voivodeship as a whole. Some counties have a surplus of men in age groups up to 59 years, while in the other age groups the number of women increases with age. In some counties have a surplus of women already in young age groups of over 30 or 34 years of age. (e.g. the Grodzisk Mazowiecki county, while other counties have such a surplus only among older age groups of over 60 years of age. (e.g. in the Ostrołęka or Siedlce counties). Interestingly, for example Warsaw sees a surplus of women as early as from the age of 20, which is partly due to an increased educational and economic migration of young women. As for the progression of the population ageing process in the counties of Mazowieckie Voivodeship, the largest share of people aged at least 65 years are recorded in the following counties: capital city of Warsaw (18.6%), Lipsko (17.5%), Sokołów Podlaski (17.3%) and Łosice (17.1%), and the smallest – in the counties of Wołomin (12.2%), Radom (12.5%), Ostrołęka (12.8%), Ostrołęka city, Piaseczno (12.9%) and Legionowo (13%). (Figures 10-13).

9 Figure 10: Share of persons under 19 Figure 11: Share of the 20-44 age group years of age in the population of in the population of Mazovian counties Mazovian counties (2014) (2014)

YEAR 2014

Share of the 0-19 age group YEAR 2014

Share of the 45-64 age group

Source: compiled based on data provided by the Central Statistical Office Source: compiled based on data provided by the Central Statistical Office

Figure 12: Share of the 45-64 age group Figure 13: Share of the 65 plus age in the population of Mazovian counties group in the population of Mazovian (2014) counties (2014)

YEAR 2014 YEAR 2014 Share of he 65 plus age Share of he 65 plus age group group

Source: compiled based on data provided by the Central Source: compiled based on data provided by the Central Statistical Office Statistical Office

10 Since there is no data available on the life by 1.2 and 0.5 years longer, respectively, expectancy at the level of counties, relevant compared to Mazowieckie Voivodeship in statistics at the level of subregions are total. The e60 parameter was the lowest in presented below (Figure 14 and Figure 15). Ciechanów subregion and it amounted to In 2014, the longest life expectancy of 18 years for men and 23.2 for women newborns (e0) in Mazowieckie Voivodeship (these figures were lower by 1.5 and 1.3 was recorded in the subregion of the year, respectively compared to the Capital City of Warsaw (76.2 years for men analysed region in total). and 82.6 years for women). These figures Figure 14: Life expectancy of a newborn were 2.3 and 0.8 years higher, respectively, in Mazovian subregions (2014) than for Mazowieckie Voivodeship in total. The values of this parameter were lowest in Ciechanów subregion. In 2014, e0 in this subregion was 71.3 years for men and 80.1

W W M M years for women. These figures were lower Years compared to the Voivodeship's total by 2.7 and 1.7 year, respectively. Life expectancy of a person aged 60 years (e60) was the longest in the subregion of the capital city of Warsaw, and it amounted to 20.6 years for men and 24.9 years for women, and was Source: compiled based on data provided by the Central Statistical Office

Figure 15: Life expectancy of a person Mazowieckie Voivodeship is considerably aged over 60 years in Mazovian diverse in terms of the fertility rate (number subregions (2014) of live births per 1000 women of childbearing age). In 2014, this index was highest in the counties (poviats) of Garwolin, Przasnysz, Łosice, Węgrów,

W M Years Mińsk Mazowiecki, Maków, Siedlce, Siedlce City and Wołomin (Figure 16). By contrast, it was lowest in the counties of Gostynin, Ostrołęka City, Płock, Ostrów Mazowiecka, Płock City, Radom City,

Sokołów Podlaski and Sierpc. Source: compiled based on data provided by the Central Statistical Office

Figure 16: Fertility rate and live births in Mazovian counties (2014)

Thousands Births per one thousand women aged 15 Birthsper aged thousand women one

Difference versus average value for voivodeship mazowieckiego: Number of births (right axis) Highervalue in the voivodeship Higher average value in county

Source: compiled based on data provided by the Central Statistical Office

As mentioned above, in 2014 the Figure 17: Population density in population density of Mazowieckie Mazowieckie Voivodeship (2014) Voivodeship was 150 people per 1 km2; however, the region is highly diversified as far as population density in individual counties is concerned. The following cities having county rights had the greatest density: capital city of Warsaw (3355 people per 1 km2), followed by the county of Siedlce City (2404 people), Radom City (1943), Ostrołęka City (1838) and Płock City (1388) (cf. Figure 17). The population density was lowest in the counties of Łosice Population per 1km2 (41), Ostrołęka (42), Maków, Przasnysz

(44), Lipsko (48), Żuromin and Sokołów Source: compiled based on data provided by the Central Podlaski (49). Statistical Office

12 1.3 Deaths due to cancers2 recorded the largest number of deaths. The analysed index was the highest for most Table 1 shows the number of deaths per age groups in this voivodeship. The lowest 100,000 people in particular age groups by number of deaths in relation to the number voivodeship in the years 2011-2013. In of inhabitants was recorded in relative terms, Łódzkie Voivodeship Podkarpackie Voivodeship.

Table 1: Number of deaths per 100,000 people by voivodeship and age group (2011- 2013)

Mazurskie

Pomorskie

Poland

Śląskie

Łódzkie

Opolskie

Lubuskie

Lubelskie

Podlaskie

Pomorskie

Age groups Age

Małopolskie

Dolnośląskie

Mazowieckie

Podkarpackie

Wielkopolskie

Świętokrzyskie

Zachodniopomorskie

Kujawsko

Warmińsko

0 564.83 508.22 441.85 568.33 443.29 393.21 387.46 475.58 496.12 447.85 419.29 531.70 479.69 482.23 417.04 536.53 461.94

1-4 21.07 25.04 23.30 18.33 20.06 13.83 19.17 14.30 15.72 19.17 22.49 16.48 20.68 21.23 17.40 20.42 19.02

5-9 12.83 14.89 11.79 12.61 10.04 9.27 10.25 7.00 10.55 11.23 8.89 10.11 6.97 14.56 10.14 13.51 10.81

10-14 15.58 18.40 16.57 20.37 16.67 11.05 13.04 9.20 13.82 15.79 12.30 15.09 11.11 19.91 14.22 15.58 14.61

15-19 50.12 39.94 50.14 57.19 46.19 37.76 49.05 44.50 40.86 45.19 44.50 39.50 37.55 50.64 42.75 53.88 44.91

20-24 65.33 57.08 74.99 64.04 73.92 51.24 65.18 57.77 58.89 66.31 57.89 63.70 68.34 74.74 54.17 68.68 63.00

25-29 69.39 70.84 82.37 75.46 87.40 46.66 74.60 59.76 54.62 79.59 55.77 74.82 66.78 79.39 62.07 72.30 68.96

30-34 87.45 89.68 107.29 103.35 131.40 72.01 90.55 63.53 76.54 95.48 70.14 95.92 107.61 106.76 79.29 88.14 90.59

35-39 138.33 138.41 152.32 144.22 208.00 112.38 141.19 118.81 110.94 138.92 121.77 158.40 158.60 160.28 128.83 143.93 142.12

40-44 238.44 241.34 246.94 261.21 324.73 188.87 240.46 188.13 183.58 214.73 211.34 271.01 250.84 233.35 216.29 223.27 235.83

45-49 395.62 394.67 391.91 414.69 518.24 334.14 387.62 328.87 298.05 356.06 352.90 430.11 394.50 382.25 364.81 396.09 387.10

50-54 691.03 629.42 635.64 688.33 825.26 553.16 673.50 594.03 507.69 587.52 605.50 702.01 623.25 683.57 620.94 639.27 649.52

55-59 1027.46 997.17 955.53 1037.15 1177.86 826.19 968.19 942.13 765.17 924.27 915.10 1068.04 929.00 1029.17 936.31 1032.63 978.46

60-64 1488.19 1483.59 1397.41 1511.65 1628.87 1260.13 1370.19 1426.42 1145.76 1312.07 1391.53 1568.69 1445.20 1519.24 1387.05 1496.99 1432.80

65-69 2036.40 2125.18 1891.66 2126.80 2239.69 1794.73 1877.35 2039.17 1719.83 1771.46 1942.65 2191.38 1907.82 2173.04 1993.56 2118.33 1998.48

70-74 2908.81 3013.81 2784.60 3069.20 3051.74 2599.65 2557.28 2995.18 2528.85 2580.43 2925.53 3074.93 2861.60 3003.55 2957.60 2959.32 2863.70

75-79 4481.96 4613.92 4410.26 4571.99 4799.82 4202.60 4173.39 4612.26 4176.29 4184.42 4400.15 4737.84 4371.62 4618.81 4567.16 4593.78 4455.69

80-84 11403.54 11387.71 11388.81 11611.65 12131.34 11134.91 10728.27 12040.76 11146.85 10381.06 10793.63 11904.34 11524.90 11265.30 11667.21 11416.45 11342.88

85+ 15037.66 15309.43 16288.59 15429.96 16623.02 15574.36 15134.67 14831.64 15538.10 15006.79 14575.31 15432.74 16005.56 15173.81 15949.55 14662.22 15462.84

Total 1041.25 969.703 1060.21 961.117 1242.16 908.401 1027.75 1001.45 870.935 999.683 878.847 1060.36 1103.86 931.255 917.646 967.427 13227.13

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Analysis of deaths due to cancer (the to cancer in the four oldest age groups were analysis considered the entire C group recorded in Pomorskie Voivodeship. according to the ICD-10 classification) A high intensity of the analysed showed the highest intensity of the phenomenon in the age groups of 25-29, analysed phenomenon in Łódzkie 30-34, 35-39, 40-44, 45-49, 50-54 was Voivodeship (cf. Table 2). Most deaths due observed in Lubuskie Voivodeship. Podkarpackie and Lubelskie Voivodeships

2 The Ministry of Health would like to give special thanks to the National Institute of Public Health – National Institute of Hygiene for preparing the analyses in this chapter.

13 had the lowest number of deaths in relative terms due to cancer, in particular in the oldest age groups.

Table 2: Number of deaths per 100,000 people due to cancers in general (C00-C97) by voivodeship and age group (2011-2013)

Poland

Śląskie

Łódzkie

Opolskie

Lubuskie

Lubelskie

Podlaskie

Mazurskie

Kujawsko

Pomorskie Pomorskie

Age groups Age

Małopolskie

Warmińsko

Dolnośląskie

Mazowieckie

Podkarpackie

Wielkopolskie

Świętokrzyskie

Zachodniopomorskie

0 1.23 0.00 3.20 0.00 0.00 6.60 1.77 0.00 1.60 6.01 7.99 2.27 2.94 0.00 3.53 6.26 2.87

1-4 2.77 3.27 3.70 5.13 4.60 1.76 3.15 4.47 5.12 4.11 1.82 3.19 0.67 3.63 2.05 3.25 3.10

5-9 1.54 4.85 2.23 1.33 2.66 2.37 2.15 0.78 3.10 1.77 1.39 2.28 2.32 4.55 3.19 3.27 2.52

10-14 2.55 2.81 2.37 2.63 4.02 1.69 1.19 0.71 2.26 2.72 1.68 2.57 0.00 0.43 2.81 2.80 2.14

15-19 442 4.38 3.89 4.90 3.06 3.21 4.12 2.31 3.78 4.35 4.40 3.07 3.84 3.23 3.35 3.61 3.72

20-24 3.70 4.41 3.91 4.18 6.61 3.95 4.18 3.18 5.02 4.03 4.62 5.54 5.20 4.86 5.65 4.49 4.68

25-29 7.74 8.28 7.66 8.09 7.31 5.18 6.12 5.21 4.64 6.33 5.01 8.01 7.86 7.05 7.69 5.43 6.75

30-34 11.37 13.04 10.77 14.98 11.66 11.72 11.20 11.21 8.55 11.21 9.47 11.75 17.71 8.45 11.07 10.93 11.36

35-39 19.46 22.57 21.05 27.82 22.67 20.30 22.08 18.83 15.24 17.66 21.50 21.72 19.69 23.12 20.97 22.63 21.11

40-44 42.31 49.46 42.38 47.35 43.92 40.96 46.12 35.40 38.17 42.18 48.40 46.94 48.56 43.23 44.10 38.72 44.07

45-49 94.96 107.08 88.77 112.80 104.43 92.32 88.75 81.98 73.66 72.79 95.24 97.37 94.80 89.52 98.71 93.85 93.35

50-54 205.77 209.74 174.99 232.78 217.62 178.10 192.11 185.05 164.88 174.65 209.59 202.42 182.62 212.93 208.46 208.17 197.68

55-59 379.98 386.32 326.56 374.83 380.62 306.65 345.09 347.22 277.84 345.61 358.34 373.30 324.08 381.08 371.69 398.70 356.21

60-64 565.24 605.92 512.76 571.22 583.33 508.91 536.20 541.81 446.43 501.41 587.44 583.52 547.31 598.49 572.19 577.91 555.23

65-69 757.95 860.66 666.33 801.50 773.61 716.58 733.95 731.77 620.29 710.48 785.81 809.87 695.89 856.02 799.69 815.36 759.91

70-74 1010.68 1082.52 866.29 1051.13 978.09 934.25 939.74 965.95 850.58 956.47 1088.72 1024.49 936.79 1053.06 1037.39 1024.62 984.33

75-79 1269.62 1341.11 1058.78 1213.48 1177.75 1192.29 1160.67 1110.23 1045.26 1213.68 1367.88 1254.92 1120.79 1359.61 1254.65 1351.03 1214.57

80-84 2337.06 2257.79 1797.78 2209.51 2090.59 2143.65 2127.41 2084.74 1822.94 2030.59 2444.22 2256.50 1931.95 2273.43 2168.95 2353.71 2149.17

85+ 1633.59 1521.49 1176.00 1513.14 1412.73 1524.45 1557.34 1347.88 1223.16 1516.97 1839.09 1435.71 1350.12 1686.18 1602.96 1580.71 1500.49

Total 263.424 257.007 221.15 243.092 272.915 224.995 248.219 239.324 192.474 239.862 247.795 263.57 246.632 242.282 235.973 256.383 245.02 Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Table 3 shows the share of deaths due to cancer versus total deaths in particular age groups. The largest share of deaths due to the analysed cause was observed in the Pomorskie Voivodeship, especially in the oldest age groups. In comparison to the other voivodeships, the state of affairs is also unfavorable in Wielkopolskie and Kujawsko-Pomorskie Voivodeships in the age groups of 45-49, 50- 54, 55-59, 60-64 and 65-69. In the Małopolskie and Lubuskie Voivodeships, cancer is a more frequent cause of death compared to the other voivodeships in the age groups of 25-29, 30-34, 35-39, 40-44, 45-49 and 50-54. Cancers have the lowest share in the causes of death in Lubuskie and Łódzkie Voivodeships, especially in the oldest age groups.

14 Table 3: Share of deaths due to cancers in general (C00-C97) versus all deaths by voivodeship and age group (2011-2013)

Mazurskie

Poland

Śląskie

Łódzkie

Opolskie

Lubuskie

Lubelskie

Podlaskie

Kujawsko

Pomorskie Pomorskie

Age groups Age

Małopolskie

Dolnośląskie

Mazowieckie

Podkarpackie

Wielkopolskie

Świętokrzyskie

Zachodniopomorskie

Warmińsko

0 0% 0% 1% 0% 0% 2% 0% 0% 0% 1% 2% 0% 1% 0% 1% 1% 1%

1-4 13% 13% 16% 28% 23% 13% 16% 31% 33% 21% 8% 19% 3% 17% 12% 16% 16%

5-9 12% 33% 19% 11% 26% 26% 21% 11% 29% 16% 16% 23% 33% 31% 31% 24% 23%

10-14 16% 15% 14% 13% 24% 15% 9% 8% 16% 17% 14% 17% 0% 2% 20% 18% 15%

15-19 9% 11% 8% 9% 7% 9% 8% 5% 9% 10% 10% 8% 10% 6% 8% 7% 8%

20-24 6% 8% 5% 7% 9% 8% 6% 6% 9% 6% 8% 9% 8% 7% 10% 7% 7%

25-29 11% 12% 9% 11% 8% 11% 8% 9% 9% 8% 9% 11% 12% 9% 12% 8% 10%

30-34 13% 15% 10% 14% 9% 16% 12% 18% 11% 12% 14% 12% 16% 8% 14% 12% 13%

35-39 14% 16% 14% 19% 11% 18% 16% 16% 14% 13% 18% 14% 12% 14% 16% 16% 15%

40-44 18% 20% 17% 18% 14% 22% 19% 19% 21% 20% 23% 17% 19% 19% 20% 17% 19%

45-49 24% 27% 23% 27% 20% 28% 23% 25% 25% 20% 27% 23% 24% 23% 27% 24% 24%

50-54 30% 33% 28% 34% 26% 32% 29% 31% 32% 30% 35% 29% 29% 31% 34% 33% 30%

55-59 37% 39% 34% 36% 32% 37% 36% 37% 36% 37% 39% 35% 35% 37% 40% 39% 36%

60-64 38% 41% 37% 38% 36% 40% 39% 38% 39% 38% 42% 37% 38% 39% 41% 39% 39%

65-69 37% 40% 35% 38% 35% 40% 39% 36% 36% 40% 40% 37% 36% 39% 40% 38% 38%

70-74 35% 36% 31% 34% 32% 36% 35% 32% 34% 37% 37% 33% 33% 35% 35% 35% 34%

75-79 28% 29% 24% 27% 25% 28% 28% 24% 25% 29% 31% 26% 26% 29% 27% 29% 27%

80-84 20% 20% 16% 19% 17% 19% 20% 17% 16% 20% 23% 19% 17% 20% 19% 21% 19%

85+ 11% 10% 7% 10% 8% 10% 10% 9% 8% 10% 13% 9% 8% 11% 10% 11% 10%

Total 25% 27% 21% 25% 22% 25% 24% 24% 22% 24% 28% 25% 22% 26% 26% 27% 24%

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Malignant neoplasms – general (C00-C97)

Cancer is the second most frequent cause of death of the inhabitants of Mazowieckie Voivodeship, as it is in all the other Polish voivodeships. In 2011-2013, it was responsible for 24.2% of deaths in Mazowieckie Voivodeship (25.4% in the case of men and 22.8% in the case of women), which closely corresponded to the cancer death rates for the Poland's total (24.5%, 26.0% and 22.8% respectively).

The actual death rate of the inhabitants of Mazowieckie Voivodeship due to cancer was 245.7 per 100,000 people, i.e. comparable to the national one (higher by 1.2%), with the difference being greater in case of women (2.6%) than men (0.4%). The surplus is in part due to the demographic structure of the Voivodeship, since the age adjustment (SMR) showed that the mortality rate in the Voivodeship is slightly lower compared to the national one. The difference is 2.5% in general, 0.8% for women and 3.8% for men.

The mortality rate due to cancer in general is significantly higher for men than for women. In the years 2011-2013, actual rates for both groups of inhabitants of Mazowieckie Voivodeship amounted to 280.8 and 214.3 per 100,000 people, respectively. After discarding age differences, the difference between men and women further increases, and the quotient of standardized rates amounts to (M/F) 1.755, which value is very similar to the national average

15 of 1.798. Cancer in general presents the greatest threat to the inhabitants of Płock county, where the mortality rate is by 16.1% higher than the national average. The surplus is similar for men (15.0%) and women (17.5%). Also in the counties of Sierpc, Płock, Płońsk, Żyrardów and Ciechanów, mortality rate due to cancer is higher than the national value by more than 10%, which is usually due to higher mortality of men. Notably, in Warsaw the standardized mortality rate indicates a mortality rate that is lower by 4.5% compared to the national one, while the actual rate is by 13.7% higher than the national one.

16 Figure 18: Total deaths due to cancers (C00–C97) (2011–2013)

M Total number W of deaths in the

voivodeship

Standardised mortality rate (SMR) rate mortality Standardised

difference versus rate value for Mazowieckie Voivodeship

higher value in the voivodeship higher value in the county value for Poland

Standardised mortality rate (SMR) rate mortality Standardised

women men value for Poland

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Trachea, bronchus and lung cancer (C33-C34)

In 2011-2013, trachea, bronchus and lung cancer was responsible for 26.8% of cancer deaths in Mazowieckie Voivodeship (34.5% in the case of men and 17.6% in the case of women), which values are considerably higher than those recorded for Poland in general (11.8% total, 11.6% for men and 12% for women, respectively).

17 The actual death rate of the inhabitants of Mazowieckie Voivodeship due to trachea, bronchus and lung cancer was 66.0 per 100,000 people, which was higher than the national death rate by 12.9%, with the difference being slightly greater for women (15.9%) than for men (12.5%). Minor differences are due to the demographic structure of the inhabitants of the Voivodeship, since the age adjustment (SMR) showed that the surplus of mortality rate in the Voivodeship has decreased to amount to 10.3% total, 13.6% for women and 9.3% for men).

The mortality rate due to trachea, bronchus and lung cancer is significantly higher for men than for women. Figure 19). In the years 2011-2013, actual rates for both groups of inhabitants of Mazowieckie Voivodeship amounted to 96.9 and 37.6 per 100,000 people, respectively. After discarding the age factor, the difference between men and women further increases, and the quotient of standardized rates amounts to (M/F) 3.28, which value is similar to the national average of 3.346.

18 Figure 19: Total deaths due to trachea, bronchus and lung cancers (C33–C34) (2011– 2013)

Total number of deaths M in the voivodeship W 10479

Standardised mortality rate (SMR) rate mortality Standardised

difference versus rate value for Mazowieckie Voivodeship

higher value in the voivodeship higher value in the county value for Poland

Standardised mortality rate (SMR) rate mortality Standardised

women men value for Poland

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

19 Breast cancer in women (C50)

In 2011-2013, breast cancer was responsible for 13.9% of total female deaths in Mazowieckie Voivodeship due to cancer, which is virtually identical to the cancer death rates for the Poland's total (13.5%).

The actual mortality rate due to breast cancer of women inhabiting Mazowieckie Voivodeship amounted to 29.8/100,000 women and it was higher by 5.6% than the national one. The differences are in part due to the demographic structure of the Voivodeship, since the age adjustment (SMR) showed that the surplus of female mortality rate in the Voivodeship is slightly lower compared to the national one and stands at 2.9%.

20 Figure 20: Total deaths due to breast cancer in women (C50) (2011— 2013)

Total number of deaths W in the voivodeship 2468

Standardised mortality rate (SMR) rate mortality Standardised

difference versus rate value for Mazowieckie Voivodeship higher value in the voivodeship higher value in the county value for Poland

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Malignant neoplasms of lower gastrointestinal tract (C18—C21)

In 2011-2013, lower gastrointestinal tract cancer was responsible for 11.5% of cancer deaths in Mazowieckie Voivodeship (11.4% in the case of men and 11.6% in the case of women), which values are virtually identical to those recorded for Poland in general (11.8% total, 11.6% for men and 12% for women, respectively).

The actual death rate of the inhabitants of Mazowieckie Voivodeship due to lower gastrointestinal tract cancer was 28.4 per 100,000 women, which was lower than the national one by 1.3%, with the difference being comparable for women (0.8%) and for men (1.4%). The differences are in part due to the demographic structure of the Voivodeship, since the age

21 adjustment (SMR) showed that the mortality rate in the Voivodeship is lower compared to the national one and stands at 6.1% total, 5.2% for women and 6.9% for men.

The mortality rate due to lower gastrointestinal tract cancer is higher for men than for women. In the years 2011-2013, actual rates for both groups of inhabitants of Mazowieckie Voivodeship amounted to 32.1 and 24.9 per 100,000 people, respectively. After discarding the age factor, the difference between men and women is further pronounced, and the quotient of standardized rates amounts to (M/F) 1.86, which value is virtually identical to the national average of 1.89.

The highest mortality rate due to lower gastrointestinal tract cancer, exceeding the national one by 25.9%, was reported in Płońsk county.(Figure 21). The surplus was almost entirely due to the increased mortality rate of men: by 43.3% compared to the Poland's total. Women's mortality rate exceeded the national one by only 4.8%. The increased mortality rate in Płońsk county was not due to the demographic structure, the actual mortality rate was 25% higher than the national one.

Mortality rate due to lower gastrointestinal tract cancer more than 10% higher than the national one was reported, in addition to Płońsk county, in the counties of Żyrardów, Grodzisk Mazowiecki, Garwolin and Legionowo.

The age structure of the inhabitants of the counties of Mazowieckie Voivodeship does not influence the conclusions from the above analyses – the standardized and actual rates remain at a similar level.

22 Figure 21: Deaths due to lower gastrointestinal tract cancer (C18–C21) (2011–2013)

Total number of deaths M in the voivodeship W 4503

Standardised mortality rate (SMR) rate mortality Standardised

difference versus rate value for Mazowieckie Voivodeship higher value in the voivodeship higher value in the county value for Poland

Standardised mortality rate (SMR) rate mortality Standardised

women men value for Poland

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

23 Malignant neoplasm of prostate (C61)

In 2011-2013, prostate cancer was responsible for 8.2% of total deaths in the Voivodeship due to cancer, which is identical to the cancer death rates for the Poland's total (8.0%).

The actual mortality rate due to prostate cancer of the inhabitants of Mazowieckie Voivodeship amounted to 23.1/100,000 people and it was higher by 3.0% than the national one. The surplus is in part due to the demographic structure of the Voivodeship, since the age adjustment (SMR) showed that the mortality rate in the Voivodeship is lower by 6.6% compared to the national one.

Figure 22: Deaths due to prostate cancers (C61) (2011-2013)

Total number of deaths M in the voivodeship 1757

mortality rate (SMR) rate mortality Standardised Standardised

difference versus rate value for Mazowieckie Voivodeship

higher value in the voivodeship value for Poland higher value in the county

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

Mortality rate due to prostate cancer in counties of Mazowieckie Voivodeship is highly diversified with a relatively small absolute number of deaths. The highest surplus above the nationwide level, i.e. 65.4%, was observed in the Białobrzegi county. High mortality rate

24 wasalso recorded in the counties of Zwoleń, Garwolin, Sierpc and Maków (62.8, 54.8, 48.5 and 42.6% above the national level, respectively). Also, in Nowy Dwór Mazowiecki, Piaseczno and Siedlce counties, mortality rate was lower than the national one by more than 40%. The age structure of the inhabitants of the counties of Mazowieckie Voivodeship does not influence the conclusions from the above analyses – the standardized and actual rates remain at a similar level. The only exception is Warsaw, where the standardized death rate indicates a mortality rate lower by 15.5% compared to the country's total, while the actual rate exceeds the national one by 17.8% (Figure 22).

Malignant neoplasm of bladder (C67)

In 2011-2013, bladder cancer was responsible for 3.4% of deaths in Mazowieckie Voivodeship due to cancer (4.9% in the case of men and 1.7% in the case of women), which closely corresponded to the cancer death rates for the Poland's total (3.7%, 5.0% and 1.7% respectively).

The actual death rate of the inhabitants of Mazowieckie Voivodeship due to bladder cancer was 8.5 per 100,000 people, which was lower than the national one by 0.6%, with the mortality rate higher among women (by 6.0%), and lower among men (by 1.6%). The differences observed are in part due to the demographic structure of the Voivodeship, since the age adjustment (SMR) showed that the reduction of mortality rate in the Voivodeship is higher compared to the national one and stands at a total of 5.9%. For women, the difference compared to the national total stands lower at 0.9%, and for men it is even higher than in the case of actual rates and it amounts to 8.4%.

The mortality rate due to bladder cancer is significantly higher for men than for women. In the years 2011-2013, actual rates for both groups of inhabitants of Mazowieckie Voivodeship amounted to 13.7 and 3.7 per 100,000 people, respectively. After discarding the differences in the demographic structure, the higher mortality rate among men is pronounced even further. The standardized rate ratio is (M/F) 5.409, which figure is only slightly lower than the national average of 5.909.

25 Figure 23: Deaths due to bladder cancers (C67)(2011-2013)

M Total number of deaths W in the voivodeship 1348

Standardised mortality rate (SMR) rate mortality Standardised

difference versus rate value for Mazowieckie Voivodeship

higher value in the voivodeship higher value in the county value for Poland

Standardised mortality rate (SMR) rate mortality Standardised

women men value for Poland

Source: based on data provided by the National Public Health Institute – National Institute of Hygiene.

26 1.4 Hospital morbidity rate

The hospital morbidity rate expresses the number of people hospitalised due to any cause or due to a particular disease entity within a year per 10,000 people3. In this document, the hospital morbidity rate relates to the hospitalisation due to cancer and, for legibility purposes, it is calculated per 100,000 people.

To make the above definition more precise, it was accepted to include patients residing in a given voivodeship only.4

The raw hospital morbidity rate was calculated and standardised. The hospital morbidity rate was calculated based on the demographic data on particular voivodeships from the Central Statistical Office and data from the NFZ database, after eliminating the effect of age and sex structure specific for each voivodeship.

Figure 24: Annual hospital morbidity: all types of cancer (2012)

all cancers – raw annual hospital morbidity rate

morbidity

all cancers – standardised annual hospital morbidity rate

morbidity

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

In terms of hospital morbidity due to all types of cancers, Mazowieckie Voivodeship was the 4th voivodeship with the highest value. The hospital morbidity rate was 822. Following the standardisation, the analysed rate slightly improved (816) and Mazowieckie Voivodeship

3 definition as in: Galus D, Zejda J.E., Uwagi w sprawie wykorzystania współczynnika chorobowości hospitalizowanej jako miernika stanu zdrowia populacji, Medycyna Środowiskowa 2002; 5(1):79-84. (as in: Śląskie Centrum Zdrowia Publicznego Ośrodek Analiz i Statystyki Medycznej Dział Chorobowości Hospitalizowanej, Zdrowie Dzieci i Młodzieży w województwie śląskim—w oparciu o dane z chorobowości hospitalizowanej, 2006); 4 In 0.69% of all the entries to the National Health Fund database analysed, an incorrect TERYT code was provided, making it impossible to unambiguously identify the administrative unit where the patient lived. In such cases, it was assumed that the inpatient's place of residence was the same as the place of treatment. Despite the incomplete data, this method shows, as accurately as possible, the real demand of a local population for oncological treatment, and hence the demand of local hospitals.

27 became the 5th one. In both cases, it was still higher than the average rate for the entire country (771), marked with a red line (Figure 24).

Malignant neoplasm of trachea, bronchus and lung (C33 — C34)

A comparative analysis of voivodeships in terms of hospital morbidity due to tracheal, bronchial and lung (hereinafter: lung) cancer group showed that Mazowieckie Voivodeship is the 7th among voivodeships with the highest rates (Figure 25). The hospital morbidity rate was 118. Following the standardisation, the analysed rate did not improve (118) and Mazowieckie Voivodeship had the same position. In both cases, it was higher than the average rate value for the entire country (113.9).

Figure 25: Annual hospital morbidity: lung cancers (2012)

lung cancers – raw annual hospital morbidity rate

morbidity

lung cancers – standardised annual hospital morbidity rate

morbidity

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

Malignant neoplasm of breast (C50, D05)

Mazowieckie Voivodeship was characterised by the 6th highest value of hospital morbidity rate due to breast cancers (90). After eliminating the effect of demographic structure, Mazowieckie Voivodeship still was on the 6th position (89). In both cases, it was higher than the rate value for the entire country (85.8).

28 Figure 26: Annual hospital morbidity: breast cancers (2012)

breast cancers – raw annual hospital morbidity rate

morbidity

breast cancers – standardised annual hospital morbidity rate

rbidity mo

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

Malignant neoplasms of lower gastrointestinal tract (C18—C21)

The value of hospital morbidity rate due to lower gastrointestinal tract cancers was 97.7 for Poland and 92 for Mazowieckie Voivodeship, which was the 5th lowest score (Figure 27). Following the standardisation, hospital morbidity in Mazowieckie Voivodeship slightly dropped to 90; however, it still remained the 5th lowest value in Poland.

Figure 27: Annual hospital morbidity: lower gastrointestinal tract cancers (2012)

lower gastrointestinal tract cancers – raw annual hospital morbidity rate

morbidity

lower gastrointestinal tract cancers – standardised annual hospital morbidity rate

morbidity

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

29 Malignant neoplasm of prostate (C61)

In 2012, Mazowieckie Voivodeship was characterised by one of the highest values of hospital morbidity rate due to prostate cancer. In terms of this particular issue, the raw rate of 50 placed this voivodeship on the 3rd position in Poland. Following the standardisation, the rate value did not change (50) and still determined the 3rd position in Poland. For Poland, the value was 43.09.

Figure 28: Annual hospital morbidity: prostate cancers (2012)

prostate cancers – raw annual hospital morbidity rate

morbidity

prostate cancers – standardised annual hospital morbidity rate

morbidity

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

Malignant neoplasm of bladder (C67)

The value of hospital morbidity rate due to bladder cancer was 83.79 for Poland and 102 for Mazowieckie Voivodeship which was the 4th lowest score. Following the standardisation, hospital morbidity in Mazowieckie Voivodeship was 100 giving it the 5th position. Thus, Mazowieckie Voivodeship came above the national rate.

30 Figure 29: Annual hospital morbidity: bladder cancers (2012)

bladder cancers – raw annual hospital morbidity rate

morbidity

bladder cancers – standardised annual hospital morbidity rate

morbidity

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

Summary of the hospital morbidity rate analysis in Mazowieckie Voivodeship in the national context

In terms of morbidity rate, the most important groups of cancers in Poland, i.e. the ones that have the highest number of new cases, are cancers of: breast, lower gastrointestinal tract and lungs. For the former ones, the highest hospital morbidity rates were observed in Łódzkie, Zachodniopomorskie and Wielkopolskie voivodeships, while the lowest rates were in Podkarpackie, Podlaskie and Opolskie voivodeships. The difference in morbidity rates between voivodeships was 46.38 of hospitalised individuals per 100 000 people, i.e. 74.83% of the value for Podkarpackie Voivodeship, and for a standardised rate - 37.37 of hospitalised individuals per 100 000 people, i.e. 57.6%.

In case of lung cancers, the highest hospital morbidity was observed in the following voivodeships: Warmińsko-Mazurskie, Zachodniopomorskie and Łódzkie, while the lowest in: Podkarpackie, Małopolskie and Podlaskie. The difference between the maximum and minimum rate was 66.32 of hospitalised individuals per 100 000 people, i.e. 83.38% of the value for Podkarpackie Voivodeship (with the lowest morbidity). Following the standardisation, the difference was 70 of hospitalised individuals per 100 000 residents, i.e. 85.28%.

As far as lower gastrointestinal tract cancers are concerned, voivodeships with the highest morbidity were: Zachodniopomorskie, Łódzkie and Wielkopolskie. Among voivodeships with the lowest morbidity were: Podkarpackie, Małopolskie and Lubelskie. The difference between voivodeships was 29.86 of hospitalised individuals per 100 000 people, i.e. 36.06% of the value

31 for Podkarpackie Voivodeship. Following the standardisation, the difference was 28.36 of hospitalised individuals per 100 000 people in a voivodeship, i.e. 33.25%.

Malignant neoplasms of testes, skin and thyroid gland were characterised by the lowest hospital morbidity. For melanoma, the highest hospital morbidity rate was in Zachodniopomorskie Voivodeship, while the lowest in Podlaskie Voivodeship. The difference between the maximum and minimum rate was 7.43 of hospitalised individuals per 100 000 people, i.e. 94.8% of the value for Podlaskie Voivodeship. Following the standardisation, this difference was 9.22 of hospitalised individuals per 100 000 people, i.e. 98.69%.

In case of testicular cancer, the highest hospital morbidity rate value was reported in Wielkopolskie, Pomorskie and Mazowieckie voivodeships, while the lowest in Podkarpackie, Opolskie and Warmińsko-Mazurskie. The rate difference between voivodeships was 5.27 of hospitalised individuals per 100 000 people, i.e. 151.21% of the value for Podlaskie Voivodeship. Following the standardisation, this difference was 5.21 of hospitalised individuals per 100 000 people, i.e. 155.37%.

The hospital morbidity rate for thyroid cancers varied significantly between voivodeships. High values were reported in Świętokrzyskie, Zachodniopomorskie and Podlaskie voivodeships, while lower ones in Opolskie, Mazowieckie and Lubelskie. The difference between the maximum and minimum rate was 29.24 of hospitalised individuals per 100 000 people, i.e. 286.12% of the value for Opolskie Voivodeship. Following the standardisation, the difference was 29.35 of hospitalised individuals per 100 000 people, i.e. 289.6%.

Summing up the analysis for Mazowieckie Voivodeship, lung cancers were a group with the highest hospital morbidity. Although the rate was high, Mazowieckie Voivodeship before and after the standardisation holds the 7th and the 8th position, respectively.

Raw and standardised values of the hospital morbidity rate due to bladder cancers indicate that it is a significant problem in Mazowieckie Voivodeship. When compared with raw and standardised rates nationally, it held, respectively, the 4th and the 5th position.

High morbidity could be observed also in case of lower gastrointestinal tract cancers, even though Mazowieckie Voivodeship had the 5th lowest value of both raw and standardised morbidity rate in Poland.

Raw and standardised values of the morbidity rate due to breast cancers indicate that it is a significant problem in Mazowieckie Voivodeship. As compared with raw and standardised rates nationally, it held the 6th position.

There is a large difference in hospital morbidity between the first four groups of cancers. Upper gastrointestinal tract cancer rate represents 75.6% of the hospital morbidity rate due to breast cancer.

32 A comparative analysis showed that in Mazowieckie Voivodeship, in contrast to other voivodeships, the following are rarely hospitalised: lower gastrointestinal tract cancers (12th position), upper gastrointestinal tract cancers (12th position) and melanoma (11th position). Mazowieckie Voivodeship is one of the leaders in terms of hospital morbidity rate due to gynaecologic (3rd position), prostate (4th position), head and neck (4th position), and kidney cancers (4th position).

Figure 30: Raw annual hospital morbidity rates per 100,000 people in Mazowieckie

Voivodeship (2012).

morbidity

melanoma

lung cancers lung

breast cancers breast

kidney cancers kidney

thyroid cancers thyroid

bladder cancers bladder

prostate cancers prostate

testicular cancers testicular

ntestinal tract cancers tract ntestinal

head and neck cancers neck and head

gynaecological cancers gynaecological

central nervous system cancers system nervous central

lower gastrointestinal tract cancers tract gastrointestinal lower upper gastroi upper

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

Figure 31: Mazowieckie Voivodeship positions in a ranking of voivodeships according

to the standardised hospital morbidity rate due to given cancers (2012)

ranking

melanoma

lung cancers lung

breast cancers breast

kidney cancers kidney

thyroid cancers thyroid

bladder cancers bladder

prostate cance prostate

testicular cancers testicular

head and neck cancers neck and head

gynaecological cancers gynaecological

central nervous system cancers system nervous central

lower gastrointestinal tract cancers tract gastrointestinal lower upper gastrointestinal tract cancers tract gastrointestinal upper

Source: compiled by DAiS based on data provided by the NFZ and Central Statistical Office.

1.5 Cancer Incidence

The number of cancer patients, newly diagnosed in 2010–2012, was established based on the data from the Polish National Cancer Registry (KRN), supplemented by the data from the Polish National Health Fund's (NFZ) reports. However, our actions were not limited to simply merging the two above-mentioned sets of data. As to the KRN, we have excluded those patients who, despite being entered therein for the first time this year, were qualified as patients

33 diagnosed earlier (so-called follow-up patients) based on medical treatment provided to them in the previous years. As to the NFZ records, we have excluded those patients who were entered in the NFZ database under a different type of cancer than in the KRN database (precedence of KRN over NFZ database). Also, we have excluded those patients whose clinical pathway was not adequate for a newly diagnosed patient with a given type of cancer. Information on the clinical pathway (covering the period of 365 days from the first date of entry in the system) included the information on reported procedures in compliance with ICD-9, reported chemotherapy and radiotherapy treatment as well as information on patient's death. Information included in the clinical pathway was used to estimate the cancer stage for patients for whom it was not specified in the KRN database.

1.5.1 Distribution of new cases in Poland

In Poland, in 2010-2012, there were over 160 thousand new cases of cancers annually, without taking into account blood cancers and non-melanoma skin cancers. This number additionally includes D05 diagnosis, i.e. carcinoma in situ of breast.In 2010-2012, the number of cases showed a slight growth and amounted to 161.7 thousand, 163.8 thousand and 164.1 thousand cases, respectively (Figure 32)5.

Figure 32: New cancer cases in Poland – including D05 and excluding C44, C81—C96

as in ICD10 (2010-2012)

Number of cases (in thousands) (in of cases Number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The highest number of new cancer cases in Poland in 2012 was observed in Mazowieckie Voivodeship (23,605 people) (Figure 33, Figure 34).6 The distribution median was 8,455

5 Differences in the number of patients presented on figures result from the process of assigning a cancer stage to a patient based on reported procedures. As in most cases it was impossible to determine the stage, we used a probability formula - for each case a stage probability was established, e.g. stage I - 0.7 and stage II - 0.3. When adding up within different variables (sex, age, region or set for a voivodeship) was performed, the number of patients was rounded to the nearest integer. Therefore, the total number of cases should be considered based on the values presented on Figure 32 and Figure 36 only, and not on the addition of microdata.

6 Because 903 individuals lacked information on the place of residence, they have not been included for further analysis. As most of these cases concerned individuals who were not listed in the payer’s database, we assume that they used private healthcare providers.

34 individuals, which means that a half of voivodeships had higher number of new cases. A high number of new cases was also observed in Śląskie (20,756), Wielkopolskie (14,136) and Małopolskie (13,168) voivodeships. These voivodeships were in the fourth quartile (Q4), meaning that they constituted one fourth of voivodeships with the highest value of the analysed variable. The lowest number of patients newly diagnosed with cancer diseases was reported in Opolskie (3,967) and Lubuskie (4,367) voivodeships.

Figure 33: Patients who were diagnosed with cancer for the first time (herein: new cancer patients) by voivodeships - including D05 and excluding C44, C81—C96 as in ICD10 (2012)

Number of patients Number of patients per 100,000 inhabitants

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 34: New cancer patients by voivodeships - including D05 and excluding C44,

C81—C96 as in ICD10 (2012)

Number of cases (in thousands) (in of cases Number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

35 To eliminate the effect of population size in particular voivodeships, we conducted an analysis of cancer incidence defined by a number of new cases per 100 thousand people. The comparative analysis using the above statistics showed that, in terms of cancer incidence, Mazowieckie Voivodeship held the first position among all voivodeships. In 2012, 445 new cancer cases per 100 thousand people were reported in the said voivodeship. Other voivodeships with the highest rate values were: Łódzkie (466), Pomorskie (463), Zachodniopomorskie (456) and Śląskie (450). A half of voivodeships had less than 421 new cancer cases per 100 thousand people, with the lowest value in Podkarpackie Voivodeship (357).

New cancer cases were analysed for 25 different groups of cancers as identified based on the international classification of diseases (ICD-10). In Poland, in 2012, there were about 164 thousand cases of cancers diagnosed in total, with the highest share of lung (16%), breast (12%), prostate (9%) and colon cancers (9%) (cf. Figure 35). Moreover, five largest cancer groups accounted for 50% of all cancer cases in Poland.

Figure 35: Share of individual cancer groups in the structure of new cancer cases (2012)

Lung

Breast

Prostate

Colon

Bladder

Kidney

Upper gastrointestinal tract

Anus and rectum

Other

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In 2012, the total completeness of the KRN database was approx. 72% of the total number of cases (listed in the KRN and supplemented with the NFZ reporting data). In the case of the first two most common cancers, i.e. lung and breast cancers, the completeness of the KRN data was approx. 80%. The exact values for individual types of cancers are shown in Figure 36. It does not include groups of other cancer groups, which amount to 6% of new cases at the national level.

Figure 36: Total number of new cancer cases in Poland by cancer type (2012)

Lung

Breast

Prostate

Colon

Bladder

Kidney

Anus and rectum

Upper gastrointestinal tract

Corpus uteri

Melanoma

Pancreas

Ovary

Cervix

Central nervous system

Thyroid

Larynx

Oral cavity

Liver

Gallbladder

Oesophagus

Testis

Nasal cavity and sinuses

Salivary gland

Lip

number of patients

Supp.

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

A four-level scale is used to determine the severity of cancers (from I to IV stage). Information

on the stages of disease is included in the KRN database, however, stage-related information

is not available for some patients, and in order to analyse healthcare needs it was necessary

to estimate the stage of disease of cancer patients from each of the 25 cancer groups.

Supplemented information on the stages of disease is shown in Figure 37. This information derives from an analysis of the treatment path of a cancer patient during the first year from the date of the diagnosis. The treatment path takes into account the procedures (according to ICD-

9 classification) reported for a patient, chemotherapy and radiotherapy treatment as well as information whether the patient lived after one year from the diagnosis. The treatment paths using NFZ data thus prepared were used to supplement the information in particular, regarding stage I (95% of the supplement) and stage IV (59% of the supplement) from the National Cancer Registry (KRN) database. This means that these stages (I and IV) are often omitted in the reports sent to the KRN.

37 Figure 37: Distribution of new cancer cases by stage of severity of the disease

(hereinafter: stage) (2012)

Number of patients (in thousands) (in of patients Number

Stage I Stage II Stage III Stage IV

Supp. KRN

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 38: Percentage distribution of new cancer cases by stage of the disease

(hereinafter: stage) (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012, the II and IV stage cancers were diagnosed most frequently (Figure 38).

Cancer groups were diversified in terms of the stage of disease (Figure 39). The earliest

detected cancers were those of the thyroid and of the endometrium, with the lowest associated share of stage IV patients. This was in stark contrast to the cancers of the pancreas, liver,

oesophagus and upper gastrointestinal tract. In these cases, at least 55% of patients were diagnosed with stage IV disease.

Figure 39: Distribution of the stage by cancer groups

Lip Lip

tract tract

Liver

Colon

Ovary Testis

Lungs Lungs

Cervix

Breast

Larynx

Kidney

Thyroid

sinuses

Bladder

Prostate

Pancreas

Melanoma

Oral cavity Oral

Gallbladder

Corpus uteri Corpus Oesophagus

Salivary gland Salivary Anus and rectum and Anus

Source: compiled by DAiS based on data provided by the KRN and the NFZ. gastrointestinal Upper

Nasal cavity and and cavity Nasal

The analysis conducted indicated that patients diagnosed with thyroid cancer, breast cancer, testicular cancer and uterine cancer (Figure 40 and Table 4) are the most likely to survive a one year period from the diagnosis (over 90%). Cancers of the pancreas, oesophagus and gall bladder are associated with the highest mortality rate. In the case of the first of the above, the odds for one-year survival from the diagnosis are only 23%. Importantly, also lung cancer patients have a very low survival rate; it was the cancer with the highest incidence rate in 2012. Changes in the survival of cancer patients that have occurred over recent years primarily relate to prostate cancer. In the case of cancers with the highest incidence rate, i.e. lung cancer and breast cancer, there are no significant changes in the survival of patients diagnosed in the years 2010-2012 and in the years 2000-2003 (Table 4). In addition, it should be noted that when it comes to cancer, the first year after the diagnosis is decisive. This is confirmed by the curves of the risk of death in a given year, provided that the patient survived the previous year. The conclusions correspond to those relating to the survival curves, i.e. patients with pancreatic, oesophageal, gallbladder and liver cancers face the highest risk of death within one year from the diagnosis. After 3 years from the date of diagnosis, the risk of death is very similar between particular cancers, which means that if the patient survives 3 years after the

39 date of diagnosis, the type of cancer will not significantly affect the chances of further survival of the patient.

Figure 40: Unconditional survival curves of cancer patients

Cancer

Thyroid

Testis

Breast

Corpus uteri

Prostate

Melanoma

Lip

Kidney

Cervix

Saliva gland

survival Bladder

Ovary

Larynx

Probability of Probability Colon

Anus and rectum

Oral cavity

Nasal cavity and sinuses

Central nervous system

Upper gastrointestinal tract

Lung

Liver

Gallbladder

Esophagus

Pancreas Time (in years)

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 41: Risk of death for patients diagnosed with cancer

Cancer

Pancreas Esophagus Gallbladder Liver Lung Upper gastrointestinal tract Central nervous system Nasal cavity and sinuses Oral cavity Colon Larynx Bladder Anus and rectum Saliva gland Ovary

Probability of death Probability Kidney Cervix Lip Melanoma Prostate Corpus uteri Testis Breast Thyroid

Time (in years)

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

40 Table 4: Survival odds

Patients diagnosed in 2010-2012 (source: Patients diagnosed in 2000-2002 data from KKN and NFZ) (source: a publication by KKN) Groups according Cancer group Unconditional Unconditional Unconditional Unconditional to ICD-10 probability of 1-year probability of 5-year probability of probability of 5- survival survival 1-year survival year survival

Lip C00 0.84 0.66

C01,C02, C03, C04, C05, Oral cavity 0.59 0.37 C06,C09,C10, C14

Salivary gland C07, C08 0.74 0.57

Nasal cavity and C11,C12,C13,C3 0.56 0.34 sinuses 0,C31

Oesophagus C15 0.29 0.11 0.27 0.05

Upper gastrointestinal C16, C26 0.42 0.23 0.35 (C16) 0.13 (C16) tract

Colon C18, C19 0.71 0.51 0.67 0.36

Anus and rectum C20, C21 0.74 0.49

Liver C22 0.32 0.16 0.23 0.08

Gallbladder C23, C24 0.29 0.14 0.21 (C23) 0.07 (C23)

Pancreas C25 0.23 0.09

Larynx C32 0.73 0.51 0.76 0.45

Lung C33, C34 0,38 0.17 0.35 0.10

Melanoma C43 0.87 0.72 0.82 0.61

Breast C50, D05 0.91 0.79 0.91 (C50) 0.69 (C50)

Cervix C53 0,78 0.60 0.80 0.51

Corpus uteri C54 0.90 0.77 0.89 0.70

Ovary C56 0.76 0.53 0.71 0.39

Prostate C61 0,89 0.74 0.80 0.48

Testis C62 0.91 0,S4 0.93 0.85

0.69 (C64, Kidney C64, C65, C66 0.76 0.63 0.46 (C64, C65) C65)

Bladder C67 0.74 0.54 0.74 0.46

Central nervous C70, C71, C72 0.48 0.33 0.45 (C71) 023 (C71) system

Thyroid C73 0.95 0.91 0.90 0.83

Source: compiled by DAiS based on data provided by the KRN and the NFZ. Ditkowska, J., Wojciechowska, U., Zatoński, W., Wskaźniki przeżyć chorych na nowotwory złośliwe w Polsce zdiagnozowanych w latach 2000-2002, Warsaw 2009

To sum up, in Poland there is a variable number of new cancer cases between voivodeships. Every year, the patients diagnosed with lung, breast, prostate and colon cancers constitute the biggest group. In cancer diseases, it is particularly important to determine the stage of cancer, however, often (especially as regards stages I and IV), the findings are not reported to the National Cancer Registry database, which is the basic source of data on cancer patients. Moreover, in Poland, pancreatic and oesophageal cancers are detected last, which account for the low survival rate of patients who suffer from them.

Malignant neoplasms of trachea, bronchus and lung (C33, C34)

In 2012, there were 25,391 new cases of cancers of the trachea, bronchus and lungs (hereinafter: lungs) reported in Poland (Figure 42). Most of them occurred in the Mazowieckie (3567) and Śląskie (3101) Voivodeships. More than half of the voivodeships recorded less than approx. 1500 new cases, and they were least numerous in the Opolskie Voivodeship (578).

Figure 42: New lung cancer cases – C33,C34 (2012)

Number of patients per 100,000 inhabitants Number of patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The incidence rate (number of new cases per 100,000 people) in Poland in 2012 amounted to approx. 65.5 on average (Figure 42, Figure 43). The value of this rate varied to a significant extent across the country, with the maximum value 20% higher than the average, and the minimal one by almost 30%. The lowest incidence rates were recorded in Warmińsko- Mazurskie (79.07) and Kujawsko-Pomorskie (78.99) Voivodeships. The lowest incidence rates, in turn, were recorded in Podkarpackie (47.37) and Małopolskie (55.48) Voivodeships. Mazowieckie Voivodeship ranked seventh in Poland in terms of the incidence of cancers of the trachea, bronchus and lungs, at 67.28 (slightly above average).

Malignant neoplasms of trachea, bronchus and lung (C33, C34)

42 In 2012, there were 25,391 new cases of cancers of the trachea, bronchus and lungs (hereinafter: lungs) reported in Poland (Figure 42). Most of them occurred in the Mazowieckie (3567) and Śląskie (3101) Voivodeships. More than half of the voivodeships recorded less than approx. 1500 new cases, and they were least numerous in the Opolskie Voivodeship (578).

Figure 43: Number of new lung cancer cases per 100, 000 people (2012)

Number of new cases per 100,000 people 100,000 per cases of new Number

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012 there were 17,234 new lung cancer cases reported among men and 8157 among women (Figure 44). The largest number of new cases was recorded in Mazowieckie Voivodeship, namely there were 2,355 new cases reported among men and 1,212 new cases among women. The share of women in the number of new lung cancer cases in this voivodeship was higher than across the country. Opolskie Voivodeship had the lowest number of new cases, namely in this Voivodeship, 416 new lung cancer cases were reported among men and 162 among women.

Figure 44: Number of new lung cancer cases in voivodeships by gender (2012)

Female

patients Male

number of number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

43 Malignant neoplasms of the breast (C50, D05)

In 2012, there were19,472 new cases of breast cancer reported in Poland (Figure 45). Most of them occurred in Mazowieckie (3,022) and Śląskie (2,487) Voivodeships. The distribution median of these cancer cases was 1016 individuals, which means that a half of voivodeships had a number of new cases exceeding that value. Opolskie Voivodeship had the lowest number (447) of new cases.

Figure 45: New breast cancer cases – C50, D05 (2012)

Number of patients per 100,000 inhabitants Number of patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The incidence rate (number of new cases per 100,000 people) in Poland in 2012 amounted to 50.5 (Figure 45, Figure 46). The value of this rate did not vary much between voivodeships, with the maximum value almost 15% higher than the average, and the minimal one by almost 20%. The highest value of the new cases incidence rate was recorded in Łódzkie Voivodeship: 57.59. The lowest incidence rates were recorded in the Podkarpackie (40.66) and Podlaskie (42.46) Voivodeships. Mazowieckie Voivodeship ranked second in the country in terms of incidence of breast cancer at 48,37 (almost 15% above the national average).

44 Figure 46: Number of new breast cancer cases per 100,000 people in voivodeships by

gender (2012)

Number of new cases per 100,000 people 100,000 per cases of new Number

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012 there were 520 new lung cancer cases reported among men and 18,952 among women (Figure 47). The largest number of new cases was recorded in Mazowieckie Voivodeship, namely there were 63 new cases reported among men and 2,959 new cases among women. The share of women in the number of new breast cancer cases in this Voivodeship was higher than across the country. Opolskie Voivodeship had the lowest number of new cases, namely in this Voivodeship, 6 new breast cancer cases were reported among men and 441 among women.

Figure 47: Number of new breast cancer cases in voivodeships by gender (2012)

Female Male

number of patients number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

45 Malignant neoplasms of colon and rectosigmoid junction (C18, C19)

In 2012, there were 14,020 new cases of colon cancer reported in Poland (Figure 48). The highest number was reported in Mazowieckie (1,974) and Śląskie (1,873) Voivodeships, more than 680 new cases were recorded in half of the voivodeships, and the lowest number was reported for Opolskie Voivodeship (349).

Figure 48: New colon cancer cases – C18, C19 (2012)

Number of patients per Number of patients 100,000 inhabitants

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The incidence rate (number of new cases per 100,000 people) in Poland in 2012 amounted to approx. 37 on average (Figure 48, Figure 49). The colon cancer incidence rate varied across the country, with the maximum value almost 15% higher than the average, and the minimal one by almost 25%. The highest values of this rate were reported in Łódzkie (42.5) and Śląskie (40.58), Voivodeships, while the lowest – in Podkarpackie (28.92) and Lubelskie (28.44) Voivodeships. Mazowieckie Voivodeship ranked eighth in terms of incidence in Poland with 37.23 new cases per 100,000 people (slightly above the Polish average).

Figure 49: Number of new colon cancer cases per 100,000 people (2012)

Number of new cases per 100,000 people 100,000 per cases of new Number

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012 there were 7,423 new lung colon cases reported among men and 6,597 among women (Figure 50). The highest number of new cases was recorded in Mazowieckie Voivodeship: 1,026 among men and 948 among women. The share of women in the number of new colon cancer casesin this Voivodeship was higher than across the country. Opolskie Voivodeship had the lowest number of new cases, namelyin this Voivodeship 186 new cases were reported among men and 163 among women.

Figure 50: Number of new colon cancer cases in voivodeships by gender (2012)

Female Male

number of patients number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasms of the rectum and anus (C20, C21)

In 2012, there were 7,706 new cases of rectum and anus cancer reported in Poland (Figure 51). Most of them occurred in Śląskie (1,026) and (1,008) Mazowieckie Voivodeships. The median of the distribution, i.e. the value above which half of the voivodeships fell, amounted to 423. Opolskie Voivodeship had the lowest number (179) of new cases.

Figure 51: New rectum and anus cancer cases – C20, C21 (2012)

Number of patients per Number of patients 100,000 inhabitants

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

47 The incidence rate (number of new cases per 100,000 people) in Poland in 2012 amounted to almost 20 on average (Figure 51, Figure 52). On the national scale, the values of this rate did not vary significantly, with the maximum value almost 23% higher than the average, and the minimal one by almost 12%. The highest values were reported for Świętokrzyskie (24.49) and Łódzkie (23.01) Voivodeships, while the lowest – for Małopolskie (17.98) and Opolskie (17.72) Voivodeships. The incidence rate of rectum and anus cancer in Mazowieckie Voivodeship ranked seventh lowest in the country at 19.01 (almost 5% below the average).

Figure 52: Number of new rectum and anus cancer cases per 100,000 people (2012)

Number of new cases per 100,000 people 100,000 per cases of new Number

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 53: Number of new rectum and anus cancer cases in voivodeships by gender

(2012)

Female Male

number of patients number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012 there were 4,422 new rectum and anus cases reported among men and 3,264 among women (Figure 53). The largest number of new cases was recorded in Śląskie Voivodeship. There were 567 new cases reported among men and 459 new cases among women. Opolskie Voivodeship had the lowest number of new cases, namely there were 105 new cases reported among men and 74 among women.

48 Malignant neoplasm of prostate (C61)

In 2012, there were 14,605 new cases of prostate cancer reported in Poland (Figure 54). Most of the cases occurred in Mazowieckie (2,343) and Śląskie (2,120) Voivodeships. The distribution median of the number of cases was 714, which means that the number of new cases exceeded that value in one half of voivodeships. Opolskie Voivodeship had the lowest number (320) of new cases.

Figure 54: New prostate cancer cases – C61 (2012)

Number of patients per Number of patients 100,000 inhabitants

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The incidence rate (number of new cases per 100,000 men) in Poland in 2012 amounted to approx. 78 (Figure 54, Figure 55). Only six voivodeships had values exceeding the national average, and the values vary across the country, with the maximum value more than 28% higher than the average, and the minimal one by 20%. The highest incidence rates in 2012 were recorded in Pomorskie (100.13) and Śląskie (95.15) Voivodeships, and the lowest – in Dolnośląskie (62.28) and Kujawsko-Pomorskie (61.7) Voivodeships. In Mazowieckie Voivodeship, the incidence rate was the third highest in the country at 92.37 (over 15% above the Polish average).

Figure 55: Number of new prostate cancer cases per 100,000 men (2012)

Number of new cases per 100,000 people 100,000 per cases of new Number

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 56: Number of new prostate cancer cases in voivodeships (2012)

number of patients number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012, there were 14,605 new prostate cancer cases reported (Figure 56). The largest number of new cases was recorded in Mazowieckie Voivodeship, namely 2,343 new cases. Opolskie Voivodeship had the lowest number of new cases, namely 320.

Malignant neoplasm of bladder (C67)

In 2012, there were 8,248 cases of bladder cancer diagnosed in Poland (Figure 57). Most of them occurred in Mazowieckie (1,105) and Śląskie (1,054) Voivodeships. The median number of new cases was 480, which means that half of the voivodeships recorded a value higher than 480, while it stood lowest in Lubuskie Voivodeship at 188.

50 Figure 57: New bladder cancer cases – C67 (2012)

Number of patients per 100,000 inhabitants Number of patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The incidence rate (number of new cases per 100,000 people) in Poland in 2012 amounted to 21.5 on average (Figure 57, Figure 58). There was a noticeable deviation of this rate comapred to the average, with the maximum value 25% higher than the average, and the minimal one by almost 28%. This rate was highest in Kujawsko-Pomorskie (26.24) and Pomorskie (25.59) Voivodeships. The lowest bladder cancer incidence was recorded in Podkarpackie (15.49) and Wielkopolskie (18.2) Voivodeships. Mazowieckie Voivodeship had the sixth lowest incidence rate in the country at 20.84 (almost 5% below the average).

Figure 58: Number of new bladder cancer cases per 100,000 people (2012)

er of new cases per 100,000 people 100,000 per cases of er new Numb

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 59: Number of new bladder cancer cases in voivodeships by gender (2012)

Female Male

number of patients number

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Poland, in 2012 there were 6,381 new bladder cancer cases reported among men and 1,867 among women (Figure 59). The largest number of new cases was recorded in Mazowieckie Voivodeship, namely there were 851 new cases reported among men and 254 new cases among women. Lubuskie Voivodeship had the lowest number of new cases. In this Voivodeship, 139 new bladder cancer cases were reported among men and 49 among women.

Figure 60 is a representation of the incidence rate values in particular voivodeships for individual cancer diseases versus total national values. It further shows the value of the age- standardized rate (versus Polish population). If the standardized value of the rate is higher than normal, it indicates a younger population than the average one in Poland: the rate value based on epidemiology is "reduced" in comparison to the young population.

Where the incidence rate is higher than in Poland, and the standardized rate is lower than the value for Poland, the higher number of cases is due to the age structure of the voivodeship rather than to epidemiological causes. An asterisk (**) is used to mark cancers for which incidence rates have been reported per 100,000 men: prostate and testicular cancers. Two asterisks (*) is used to mark cancers for which incidence rates have been reported per 100,000 women (ovarian, cervical and endometrial cancers). Otherwise, a rate per 100,000 inhabitants is shown.

52 Figure 60: Comparison of cancer incidence rates (2010-2012)

Prostate

Trachea, bronchus and lung

Breast

Colon

Corpus uteri

Ovary

Bladder

Upper gastrointestinal tract

Cervix

Anus and rectum

Kidney

Pancreas

Melanoma cancers Central nervous system

Testis

Thyroid

Larynx Oral cavity

Gallbladder

Liver

Oesophagus

Nasal cavity and sinuses

Salivary gland

Lip

Other

incidence per 100,000 inhabitants/men/women

Poland

Mazowieckie – standardized to the age structure (in Poland) Mazowieckie

Source: compiled by DAiS based on data provided by the NFZ.

53 Table 5 shows directly standardized incidence rates for voivodeships and the value for Poland. After discarding the age factor, for most diagnoses, the highest values were recorded in Śląskie, Łódzkie, Świętokrzyskie and Mazowieckie Voivodeships, and the lowest in Warmińsko-Mazurskie, Podkarpackie and Lubuskie Voivodeships. An asterisk (*) is used to mark cancers for which incidence rates have been reported per 100,000 men or women. Otherwise, a rate per 100,000 inhabitants is shown.

Table 5: Age-standardized incidence rates by voivodeships and in Poland (2010-2012)

Dolnośląskie Kujawsko Pomorskie Lubelskie Lubuskie Łódzkie Małopolskie Mazowieckie Opolskie Opolskie Podkarpackie Podlaskie Śląskie Świętokrzyskie Warmińsko Mazurskie Wielkopolskie Zachodniopomorski e Poland

Central nervous system 10.57 10.29 1D,4 3.33 11.12 11.24 10.94 10.15 3.13 3.23 10.15 11)45 10.51 3.57 9.33 5.7 10.5

Melanoma 11,5S 10.31 10.54 9.77 12.34 12.3 12.25 1-675 1-657 10.11 11.16 12)92 12.33 9.47 9.36 16 3 11.4

Upper gastrointestinal tract 16.31 1471 15.6 1453 16.36 15.57 16.37 1461 1416 15.41 1466 15.33 16/2 14 1433 15.22 21.1

Prostate* 76.6 72.31 7^54 63.22 53.03 75.47 30.56 73.27 71.31 77.33 73.31 52/3 51.31 66.3 63.66 73.34 76.4

Ovary* 23.61 23.04 22.54 20.36 25.25 24.11 24/07 22.45 20.21 21.54 22.75 25.59 2 4 OB 21.15 22.37 22.36 23.4

Nasal cavity and sinuses 4.35 3.25 3.36 3.47 4.16 3.53 453 3.79 3.14 2.33 4.13 44 3.45 3)1 3.42 3.57 3.9

Oral cavity 7.9 6.39 6.3 7.03 615 7.35 611 7.72 615 6.17 7.51 3)35 7.47 5.33 7.14 7.2 7.6

Testis* 5.43 5)15 7.52 633 676 9.67 7.39 6)5 5.63 3.43 3.57 7.41 6.42 654 7.39 8.2

Colon 37.23 34)31 36.43 33.77 39.46 35.31 37.57 37.21 33.73 36.12 34.34 35 3673 32.13 33.63 35.33 36.1

Larynx 5.23 7.79 7.33 6.55 654 7.65 8.3 7.27 6.65 6.63 7.64 633 7.55 7.06 7.37 7.63 7.9

Kidney 23.25 13.16 15.34 15.79 21.75 20/04 2Ą71 20.29 13.42 15.23 19.27 21.55 20.64 17.93 1677 13 20.0

Anus and rectum 21.24 13.63 2Ą4 ? 13.05 22.71 20.36 21.45 2Q79 ? 13.23 20.22 13.62 22.04 22.35 17.37 13.2 13.65 20.6

Bladder 22.55 21.57 22.15 13/3 2426 21.95 23.01 21.33 20.46 21.71 21.01 23/ 2405 19.45 13.36 21.04 22.0

Gallbladder 5.43 5.22 4.35 4.36 6.54 6.2 6.36 5.21 4.39 5,0S 5.65 6/1 6.3 423 5.23 5.64 5.8

Breast 42.25 33.32 33.32 40.31 42.61 35.51 4Ą37 40.52 37.92 33/05 39.27 41)32 41.7 35,5^ 33.36 41.35 50.3

Other 24.3 23.25 23.65 22.45 2647 24.27 25.53 24.04 22.05 23.2 23.52 26/02 25.45 21.53 22.64 23.65 25.3

Oesophagus 5.11 4.62 3.53 3.63 5.61 5.37 5.25 4.62 3.41 3.59 5/39 5.55 453 3)53 4.42 4.7 4.8

Cervix* 22.25 19.34 13.47 2Q73 21.31 21.25 22.45 20.56 17.6 13.46 21.27 23.4 2Ą 72 19.32 13.33 21.23 21.1

Salivary gland 1.61 1.33 1.26 0,B7 2.15 1.32 2.53 0.56 1.32 1.15 1.73 1.62 1.23 0.92 1.54 1.15 1.6

Thyroid 7.14 7.07 6.7 66 631 5.15 636 6.04 671 7.67 8.39 8.53 569 6,4^ 613 615 8.0

Trachea, bronchus and lung 67.6 63.54 65.56 62.7 71.26 62.9 66.71 66.72 60.5 64.2 62.02 63.03 6574 60.23 61.09 6477 65.2

Corpus uteri* 32.3B 23.36 3Q7 30.26 33.25 30.79 32.45 3Q74 25,3^ 29.27 23.23 3657 32.15 27.06 2634 23.6 31.0

Pancreas n,ee 11.03 10.53 10.42 13.07 12,OS 12.43 11.62 10.33 10.43 11.14 12.37 12.5 3.32 10.65 11.11 11.6

Lip 0.53 1.04 1.75 0.94 2.02 1.35 2.54 1.34 1.33 1.63 1.27 0.98 2.19 0.89 1.23 1.00 1.5

Liver 6.43 5.13 4.53 4.52 676 5.37 6.42 4.7 4.2 4.87 6.17 6.64 5.5 4.64 5.32 5.43 5.7 Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office.

1.5.2 Distribution of new cases in the voivoideship

In Mazowieckie Voivodeship in 2012, the most frequent diagnoses included cancers of the trachea, bronchus and lung, breast and colon. Their share in the structure of new cases did not differ significantly from the structure in Poland, as shown in Figure 61, which shows the shares of major cancer groups constituting in total approx. 80% of all new diagnoses in 2012. The largest absolute difference between the percent share of a cancer in a voivoideship and

54 in Poland was recorded for prostate cancer; in Poland, the share of this cancer group was by 0.97 percentage points lower than in Mazowieckie Voivodeship. The exact values of shares of individual cancer groups in Poland and in the voivoideship are shown in Table 6. There were also noticeable variations for breast and upper gastrointestinal tract cancers. Cancers of the testis, nasal cavity and sinuses, salivary glands and lips had the lowest shares in the cancer structure in Mazowieckie Voivodeship.

Table 6: Share of new cancer cases in Mazowieckie Voivodeship in the national context

Share in the Share in Difference in Cancers voivoideship Poland percentage points

Trachea, bronchus and lung 15.23% 15.63% -0.40%

Breast 12.80% 11.95% 0.85%

Prostate 9.91% 8.95% 0.97%

Colon 8.24% 8.49% -0.25%

Bladder 4.66% 5.04% -0.39%

Kidney 4.95% 4.73% 0.22%

Anus and rectum 4.26% 4.72% -0.45%

Upper gastrointestinal tract 4.08% 4.71% -0.63%

Corpus uteri 4.06% 3.89% 0.18%

Melanoma 2.88% 2.96% -0.08%

Pancreas 2.93% 2.93% 0.00%

Ovarian 2.67% 2.78% -0.11%

Cervical 2.71% 2.53% 0.18%

Central nervous system 2.32% 2.46% -0.14%

Thyroid 2.14% 1.98% 0.16%

Larynx 1.56% 1.82% -0.26%

Oral cavity 1.81% 1.76% 0.04%

Liver 1.55% 1.44% 0.11%

Gallbladder 1.60% 1.40% 0.20%

Oesophagus 1.08% 1.18% -0.10%

Testis 1.07% 0.98% 0.09%

Nasal cavity and sinuses 0.86% 0.91% -0.05%

Salivary gland 0.50% 0.41% 0.09%

Lip 0.43% 0.35% 0.07%

Other 5.71% 6.00% -0.29% Source: compiled by DAiS based on data provided by the KRN and the NFZ.

55 It was found based on the analysis of Figure 62 that cancers of the trachea, bronchus and lungs, breast, colon, prostate and cancers not assigned to any of the groups analysed, in total accounted for a half of new cancer cases in Mazowieckie Voivodeship (Figure 62).

The situation in terms of the number of newly diagnosed cancer cases was very similar to that in the years 2010 and 2011 (Table 7). In 2012, there were most lung cancer cases diagnosed, i.e. 3,567. This correlation also occurred in the years 2010-2011. Interestingly, between 2010 and 2012, the number of cases remains virtually unchanged, which makes it possible to identify a trend in the number of cases of this cancer in the years 2010-2012. Breast cancer was the second most common cancer in the years 2010-2012. In 2012, 3,022 new diagnoses were made, and 2,887 and 2,710 in 2010 and 2011, respectively. These figures make it possible to identify an upward trend in the number of new cases of this cancer in the years 2010-2012. The salivary gland and lip cancers were most rarely diagnosed cancers in the years 2010- 2012. In 2012, they constituted 119 and 102 cases, respectively.

Table 7: New cancer cases in Mazowieckie Voivodeship (2010-2012)

Incidence Cancer Year 2010 Year 2011 Year 2012 3 years

Trachea, bronchus and lung 3559 3571 3567 67.47

Breast 2710 2887 3022 54.36

Prostate 2523 2726 2343 100.05

Colon 2000 2044 1974 37.96

Kidney 1205 1225 1171 22.71

Bladder 1168 1162 1105 21.67

Anus and rectum 1092 1027 1008 19.72

Upper gastrointestinal tract 1096 1015 982 19.51

Corpus uteri 904 1027 957 34.94

Melanoma 662 731 679 13.07

Pancreas 631 657 675 12.38

Cervical 640 607 640 22.83

Ovarian 644 677 632 23.63

Central nervous system 520 569 526 10.19

Thyroid 497 483 505 9.37

Oral cavity 423 401 433 7.93

Larynx 382 424 373 7.44

Gallbladder 368 366 371 6.97

Liver 320 345 355 6.43

Oesophagus 231 223 261 4.51

56 Testis 224 260 251 9.69

Nasal cavity and sinuses 201 197 207 3.82

Salivary gland 89 113 119 2.02

Lip 86 101 102 1.82

Other 1416 1458 1421 27.09 Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office.

Figure 61: Share of the main cancer groups in Mazowieckie Voivodeship in the national context

Share in the voivoideship Trachea, bronchus and lung Share in Poland

Pancreas Breast

Melanoma Prostate

Corpus uteri Colon

Upper gastrointestinal tract Bladder

Anus and rectum Kidney

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

57 Figure 62: New cancer cases in Mazowieckie Voivodeship (2012)

Testis

number of new cases of new number

Lip

Liver

Other

Colon

Ovary Testis

Cervix

Breast

Larynx

Kidney

Thyroid

Bladder

Prostate

Pancreas

Melanoma

Oral cavity

Gallbladder

Corpus uteri Corpus

Oesophagus

Salivary gland Salivary

nervous system nervous

Anus and rectum Anus and

Central Central

Nasal cavity and sinuses Nasal cavity

Upper gastrointestinal tract gastrointestinal Upper

Trachea, bronchus and lung bronchus Trachea, Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasms of trachea, bronchus and lung (C33, C34)

The largest share in the number of new cases of trachea, bronchus and lung (hereinafter: lung) cancers in Poland in 2012 was recorded in the 55-64 age group, and the lowest – in the 0-44 age group (Figure 63). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 55-64 age group, which accounted for 36% of all new cancer cases in this group

• the least new cases were recorded in the 0-44 age group, which accounted for 1% of all new cancer cases in this group

A smaller share in new cases of trachea, bronchus and lung cancer (versus Poland) was reported for 55-64 (36%), 45-54 (9%), 85+ (3%) and 0-44 age groups (1%). The 65-74 (32%) and 75-84 (20%) age groups had a larger share in new cancer cases in this group (versus Poland). The distribution by age group in Mazowieckie Voivodeship was similar to the distribution observed across Poland.

58 Figure 63: Share of new lung cancer cases by age group in Mazowieckie Voivodeship

(2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of trachea, bronchi and lung cancer in Mazowieckie Voivodeship in 2012 were at stage IV, i.e. 1,921 (Figure 64). This accounted for 53% of all cases recorded (Figure 65). Stage III ranked second in terms of occurrence at 33%. Stages I and II represented in total 14% of all recorded cancer cases in this group. The distribution of new cases by stage was clearly under-represented in terms of stage II versus the national distribution (Figure 66).

Figure 64: Number of new lung cancer cases by stage of severity in Mazowieckie

Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

59 Figure 65: Share of new lung cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry and the NFZ.

Figure 66: Share of new lung cancer cases by stage of severity in Mazowieckie

Voivodeship and in Poland (2012)

% share %

Stage I Stage II Stage III Stage IV higher value in the voivodeship higher value in Poland

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasms of the breast (C50, D05)

The largest share in the number of new cases of breast cancer in Poland in 2012 was recorded in the 55-64 age group, and the lowest – in the 85+ age group (Figure 67). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 55-64 age group, which accounted for 35% of all new cancer cases in this group

• the least new cases were recorded in the 85+ age group, which accounted for 3% of all new cancer cases in this group

A smaller share in new cases of breast cancer (versus Poland) was reported for 65-74 (20%), 45-54 (19%) and 0-44 age groups (10%). The 55-64 (35%), 75-84 (13%) and 85+ (3%) age groups had a larger share in new cancer cases in this group (versus Poland). In comparison to the distribution observed in Poland, the distribution of new breast cancer cases in Mazowieckie Voivodeship was over-represented by the 55-64 age group in relation to the distribution observed across Poland.

Figure 67: Share of new breast cancer cases by age group in Mazowieckie Voivodeship

and in Poland (2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of breast cancer reported in Mazowieckie Voivodeship in 2012 were at stage II, i.e. 1,388 (Figure 68). These accounted for 46% of all cases recorded (Figure 69). The distribution of new cases of breast cancer in Mazowieckie Voivodeship was similar to that observed across Poland (Figure 70).

Figure 68: Number of new breast cancer cases by stage of severity in Mazowieckie

Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

61 Figure 69: Share of new breast cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 70: Share of new lung breast cases by stage of severity in Mazowieckie

Voivodeship and in Poland (2012)

% share %

Stage I Stage II Stage III Stage IV higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasms of colon and rectosigmoid junction (C18, C19)

The largest share in the number of new cases of colon cancer in Poland was recorded in the 65-74 age group, and the lowest – in the 0-44 age group (Figure 27). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 75-84 age group, which accounted for 30% of all new cancer cases in this group

• the least new cases were recorded in the 0-44 age group, which accounted for 3% of all new cancer cases in this group

The 65-74 (28%), 55-64 (23%) and 45-54 (8%) age groups had a smaller share in new cancer cases in this group (versus Poland). The 75-84 (30%), 85+ (8%) and 0-44 (3%) age groups had a larger share in new cancer cases in this group (versus Poland). The distribution of new breast colon cases in Mazowieckie Voivodeship was over-represented by people aged 75 in relation to the distribution observed across Poland.

62 Figure 71: Share of new colon cancer cases by age group in Mazowieckie Voivodeship

and in Poland (2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of colon cancer in Mazowieckie Voivodeship in 2012 were at stage III, i.e. 726 (Figure 72). This accounted for 37% of all cancer cases in this group (Figure 73). Shares of Stage II and IC were similar and they accounted for a half of all new cases.

The distribution of new breast colon cases in Mazowieckie Voivodeship was highly over- represented by stage III in relation to the distribution observed across Poland (Figure 74).

Figure 72: Number of new colon cancer cases by stage of severity in Mazowieckie

Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

63 Figure 73: Share of new colon cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 74: Share of new colon cancer cases by stage of severity in Mazowieckie

Voivodeship and in Poland (2012)

% share %

Stage I Stage II Stage III Stage IV higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasms of the rectum and anus (C20, C21)

The largest share in the new cases of rectum and anus cancers in Poland was recorded in the 65-74 age group, and the lowest – in the 0-44 age group (Figure 75). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 65-74 age group, which accounted for 29% of all new cancer cases in this group

• the least new cases were recorded in the 0-44 age group, which accounted for 3% of all new cancer cases in this group

The 65-74 (29%), 55-64 (27%) and 45-54 (7%) age groups had a smaller share in new cancer cases in this group (versus Poland). The 75-84 (28%), 85+ (6%) and 0-44 (3%) age groups had a larger share in new cancer cases in this group (versus Poland). The distribution of new rectum and anus colon cases in Mazowieckie Voivodeship in terms of age groups was over- represented by people aged 75 in relation to the distribution observed across Poland.

Figure 75: Share of new rectum and anus cancer cases by age group in Mazowieckie

Voivodeship and in Poland (2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of rectum and anus cancer in Mazowieckie Voivodeship in 2012 were at stage III, i.e. 371 (Figure 76). This accounted for 37% of all cancer cases in this group (Figure

77). The distribution of new rectum and anus colon cases in Mazowieckie Voivodeship was substantially over-represented by stage III in relation to the distribution observed across Poland (Figure 78).

Figure 76: Number of new rectum and anus cancer cases by stage of severity in

Mazowieckie Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

65 Figure 77: Share of new rectum and anus cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 78: Share of new rectum and anus cancer cases by stage of severity in

Mazowieckie Voivodeship and in Poland (2012)

% share %

Stage I Stage II Stage III Stage IV higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasm of prostate (C61)

The largest share in the number of new cases of prostate cancer in Poland was recorded in the 65-74 age group, and the lowest – in the 0-44 age group (Figure 79). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 65-74 age group, which accounted for 38% of all new prostate cancer cases in this group

• almost no new cases were recorded for the 0-44 age group

The 65-74 (38%), 55-64 (26%) and 45-54 (3%) age groups had a smaller share in new prostate cancer cases in this group (versus Poland). The 75-84 (27%), 85+ (5%) and 0-44 (0%) age groups had a larger share in new prostate cancer cases in this group (versus Poland). The distribution of new prostate cases by age group in Mazowieckie Voivodeship was similar to that observed across Poland.

Figure 79: Share of new prostate cancer cases by age group in Mazowieckie Voivodeship and in Poland (2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of prostate cancer reported in Mazowieckie Voivodeship in 2012 were at stage II, i.e. 744 (Figure 80). This accounted for 32% of all observed cases (Figure 81). New cases in Stage I and III accounted for almost a half of all new prostate cancer cases. The distribution of new cases in terms of stage was substantially over-represented by Stage III and IV in relation to the distribution observed across Poland (Figure 82).

67 Figure 80: Number of new prostate cancer cases by stage of severity in Mazowieckie

Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 81: Share of new prostate cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 82: Share of new prostate cancer cases by stage of severity in Mazowieckie

Voivodeship and in Poland (2012)

Percentageshare

Stage I Stage II Stage III Stage IV higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

68 Malignant neoplasm of bladder (C67)

The largest share in the new cases of bladder cancer in Poland was recorded in the 65-74 age group, and the lowest – in the 0-44 age group (Figure 83). In Mazowieckie Voivodeship, the situation was as follows:

• the most new cases were recorded in the 65-74 age group, which accounted for 31% of all new cancer cases of this type in this group

• the least new cases were recorded in the 0-44 age group, which accounted for 2% of all new cancer cases of this type in this group

The 55-64 (24%) and 45-54 (5%) age groups had a smaller share in new bladder cancer cases in this group (versus Poland). A larger share in new cases of bladder cancer (versus Poland) was reported for 65-74 (31%), 75-84 (28%), 85+ (9%) and 0-44 age groups (2%). The distribution in terms of age groups was over-represented by people aged over 65 in relation to the distribution observed across Poland.

69 Figure 83: Share of new bladder cancer cases by age group in Mazowieckie Voivodeship

and in Poland (2012)

Number of new cases (% of Number(% population) newcases of

higher value in Poland higher value in the voivodeship higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Most new cases of bladder cancer in Mazowieckie Voivodeship in 2012 were at stage III, i.e. 472 (Figure 84). This accounted for 43% of all cancer cases of this type (Figure 85). Stage I had the smallest share (5%) in the new bladder cancer cases.

The distribution of new colon cases of this type in Mazowieckie Voivodeship was substantially over-represented by stage III and IV in relation to the distribution observed across Poland (Figure 86).

Figure 84: Number of new bladder cancer cases by stage of severity in Mazowieckie

Voivodeship (2012)

Numberof new cases

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

70 Figure 85: Share of new bladder cancer cases by stage of severity in Mazowieckie Voivodeship (2012)

Stage

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 86: Share of new bladder cancer cases by stage of severity in Mazowieckie

Voivodeship and in Poland (2012)

Percentageshare

Stage I Stage II Stage III Stage IV higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Structure of new cases in Poland

It is also possible to determine the 3-year incidence rate for individual counties of Mazowieckie Voivodeship. Due to the number of cases, its value was determined for four major cancer groups (lung, breast, colon and prostate) accounting to almost 50% of cancers in Mazowieckie Voivodeship.

There were a total of 3,567 cases of cancer of trachea, bronchus and lung reported in 2012 in Mazowieckie Voivodeship. Warsaw had a particularly high incidence (1,248 cases) with almost 10 times more cases recorded than in Radom, a county city that ranked second (133) (Figure 87). Counties with a high number of new cases formed 3 clusters. The first and largest one was centred around Warsaw; the second one – around Radom, and the third one in the area of Płock, Płońsk and Ciechanów. The median number of new cases was 56, which means that in half of the counties of Mazowieckie Voivodeship there were more than 56 new cases of trachea, bronchus and lung cancers, and less than that in the other half. The lowest number of new cases was recorded in the counties of Łosice (11), Białobrzegi (20) and Zwoleń (21). Thus, it can be stated that there are substantial differences in the number of new cases of lung cancer in individual counties.

Figure 87: New lung cancer cases in Mazowieckie Voivodeship (2012)

Number of new cases

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

These differences, however, are most likely due to the number of inhabitants, so that the number of new cases was related to the number of county inhabitants. In some counties the rate of 3-year incidence was used in relation to 10,000 people due to small number of new cases (Figure 88). It indicates correlations other than for absolute values. The highest rate values were reported in counties from the western-northern part of the Voivodeship. Among them, the highest values were recorded in the counties of Gostynin (8.89), Sierpc (8.87), Ciechanów (8.46) and Płock City (9.37). The lowest rate values were reported for the counties from the eastern region of the Ostrołęckie (3.99) and Siedleckie (4.72) Voivodeships. The difference between the smallest and the largest rate value for the counties amounts to up to 135%.

72 Figure 88: 3-year incidence rate: lung cancer (2010-2012)

3-year incidence per 10,000 people

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ, the BDL and the Main Statistical Office.

There were 3,022 new breast cancer cases in Mazowieckie Voivodeship. Warsaw had a particularly high incidence (1,271 cases) with almost 10 times more cases recorded than in Radom, a county city that ranked second (138) (Figure 89). Figure 89 shows a cluster of counties with a large number of new cases in the centre of the Voivodeship. The median number of new cases was 35, which means that in half of the counties of Mazowieckie Voivodeship there were more than 35 new cases of breast cancer, and less than that in the other half. The lowest number of new cases was recorded in the counties of Zwoleń (13) and Przysucha (14).

73 Figure 89: New breast cancer cases in Mazowieckie Voivodeship (2012)

Number of new cases

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Deviations in the number of cases are due to differences in the number of population, as well as differences in age and gender structures in counties, so that the number of new cases was studied against the number of inhabitants of individual counties. In some counties the 3-year incidence rate was used in relation to 10,000 people due to low values (Figure 90). It can be seen that the majority of counties with a high 3-year incidence are located in the central part of the Voivodeship, namely the counties of Pruszków (5.79), Grodzisk Mazowiecki (5.86), Sochaczew (5.72), Warsaw West (5.51), Otwock (5.03) and Warsaw (7.31). The lowest rate values were reported for Ostrołęka (2.47) and Lipsko (2.67) counties. The difference between the smallest and the largest rate value for the counties amounts to up to 196%.

74 Figure 90: 3-year incidence rate: breast cancer (2010-2012)

3-year incidence per 10,000 people

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office.

In 2012, there was a total of 1,974 colon cancer cases reported across Mazowieckie Voivodeship. Warsaw had a particularly high incidence (783 cases) with almost 10 times more cases recorded than in Radom, a county city that ranked second (87) (Figure 91). Figure 91 shows a cluster of counties with a large number of new cases in the centre of the Voivodeship. The median number of new cases was 24, which means that in half of the counties of Mazowieckie Voivodeship there were more than 24 new cases of colon cancer, and less than that in the other half. The lowest number of new cases was recorded in the counties of Szydłowiec and Białobrzegi (9 in each).

75 Figure 91: New breast colon cases in Mazowieckie Voivodeship (2012)

Number of new cases

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

These pronounced differences in the number of cases are due to differences in the number of population, as well as differences in age and gender structures in counties, so that the number of new cases was studied against the number of inhabitants of individual counties. In some counties the rate of 3-year incidence was used in relation to 10,000 people due to small number of new cases (Figure 92). High rate values were recorded in the county city of Warsaw (4.82) as well as counties of Otwock (4.54) and Łosice (4.51). The lowest rate values were reported for Szydłowiec (1.96) and Nowy Dwór Mazowiecki (2.26) counties. The difference between the smallest and the largest rate value for the counties amounts to up to 146%.

76 Figure 92: 3-year incidence rate: colon cancer (2010-2012)

3-year incidence per 10,000 people

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office.

There were a total of 2,343 prostate cancer cases in 2012 in Mazowieckie Voivodeship. Warsaw had a particularly high incidence (1,033 cases) with over 11 times more cases recorded than in Wołomin, a county that ranked second (88) (Figure 93). Figure 93 shows a cluster of counties with a large number of new cases in the centre of the Voivodeship. The median number of new cases was 26, which means that in half of the counties of Mazowieckie Voivodeship there were more than 26 new cases of prostate cancer, and less than that in the other half. Białobrzegi County had the lowest number (3) of new cases. Thus, there are substantial differences in the number of new cases of prostate cancer in individual counties.

77 Figure 93: New breast prostate cases in Mazowieckie Voivodeship (2012)

Number of new cases

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

These differences, however, are due to the varying number of inhabitants, so that the number of new cases was adjusted for the demographic structure. In some counties the rate of 3-year incidence was used in relation to 10,000 people from the population at risk of the disease due to small number of new cases (Figure 94). It can be noted that counties with highrate values are located mostly around Warsaw. Highest rate values were recorded in the county city of Warsaw (15.61) as well as in Siedlce (10.91) and in the county of Legionowo (11.85). The lowest rate values were reported for Białobrzegi (3.12) and Szydłowiec (3.78) counties. The difference between the smallest and the largest rate value for the counties amounts to up to 400%.

78 Figure 94: 3-year incidence rate: prostate cancer (2010-2012)

3-year incidence per 10,000 people

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office.

79 CATCHING GAPS WITH HEALTHCARE MAPS CARDIOLOGY AND ONCOLOGY

Part II Status and Use of Resources: the Analysis

80 2.1 Hospitalisation

2.1.1 Healthcare providers in Poland

In 2012, 806 hospitals provided oncological treatment within the scope of analysed cancer group in Poland7.Figure 95 illustrates the geographic distribution of those healthcare providers, accurate to a county8.

Figure 95: Hospitals providing treatment to cancer patients

Number of hospitals

No hospital 1 (2-5) (5-15) (15-30) (30-42)

Source: compiled by DAiS based on data provided by the NFZ.

In some counties (25), there is no hospital providing cancer treatments at all. These counties, however, are scattered across the country and they are adjacent to counties with at least one hospital that provides oncological healthcare. In most counties, there are one (215) or 2 to 5 facilities (118). Most providers are located in largecities, primarily in Warsaw (42), Katowice (23), Łódź (22) and Kraków (20). A large density of hospitals is present in Śląskie Voivodeship, in which there are many city counties, with more than two treatment providers in most of them.

Out of 809 hospitals analysed accounting for oncological treatments, 98 healthcare providers treated 80% of patients with oncology-related diagnoses9. The names of these facilities together with the number of patients treated in 2012 were listed from the highest values (Table 8).

7 According to the definition above, the analysis covered cancer-related treatments without oncohematology and without skin cancers (excluding melanoma). For the sake of clarity, these treatments will be hereinbelow referred to as cancer treatments. 8 A provider with two facilities in one county is indicated once on the map, whereas if it has branches in different counties, it is included in each of these. In other words, a provider is counted once in each county. 9 The percentage of patients on a national scale is defined as the number of patients admitted with a cancer diagnosis analysed versus the unique number of cancer patients in Poland. In other words, the patient admitted to two different hospitals will be included in the numerator in each of them, but only once in the nominative. As a consequence, the sum of this variable for the table including all facilities providing cancer treatment in the country would exceed 100%.

81 Based on the analysis of data from Table 8, it was concluded that within the analysed period most patients were treated in Maria Skłodowska-Curie Institute of Oncology. In the Warsaw branch, the number of patients was over 11.3 thousand, and in the Gliwice branch – almost 5.5 thousand. In total, this represents 7.1% of hospitalised patients with a cancer diagnosis on a national scale.

The next two largest facilities in terms of the number of patients to whom oncological treatments were provided are Nicolaus Copernicus Regional Specialist Hospital in Łódź and the Professor Franciszek Łukaszczyk Oncology Centre in Bydgoszcz The first one admitted 6.7 thousand patients (2.9% of cancer patients), and the other – 6.4 thousand patients (2.7% of cancer patients).

The share of patients of more than 2% in the national scale was observed in two more institutions: These included: Maria Skłodowska-Curie Wielkopolskie Oncology Centre in Poznań and Świętokrzyskie Oncology Centre in Kielce

Other facilities admitted lower number of patients, with 19 hospitals having a share of over 1% of hospitalised patients with oncological diagnoses treated in Poland, while another 55 hospitals, a share of 0.5% or more.

Table 8: Hospitals treating approx. 80% of cancer patients (2012)

Number of Percentage Cumulative Ite Name of the treatment provider patients of patients percentage m

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw 11324 4.8% 4.8%

2 Nicolaus Copernicus Regional Specialist Hospital in Łódź 6,737 2.9% 7.7%

3 Professor Franciszek Łukaszczyk Oncology Centre in Bydgoszcz 6,377 2.7% 10.4%

4 Maria Skłodowska-Curie Wielkopolskie Oncology Centre in Poznań 5,685 2.4% 12.8%

5 Maria Skłodowska-Curie Institute of Oncology Gliwice Branch 5,455 2.3% 15.1%

6 Świętokrzyskie Oncology Centre in Kielce 4,899 2.1% 17.2%

7 University Clinical Centre in Gdańsk 4,483 1.9% 19.1%

8 Zachodniopomorskie Oncology Centre in Szczecin 4,231 1.8% 20.9%

9 Oncology Centre Hospital - Kraków Division Institute 3,915 1.7% 22.6%

10 University Hospital Healthcare in Kraków 3,910 1.7% 24.3%

11 Dolnośląskie Oncology Centre in Wrocław 3,829 1.6% 25.9%

Independent Public Healthcare Centre of the Ministry of Internal Affairs with Warmińsko-Mazurskie Oncology Centre in 12 3,374 1.4% 27.3% Olsztyn

13 Military Institute of Medicine in Warsaw 2,942 1.3% 28.6%

14 St. John of Dukla Lublin Regional Oncology Centre Independent Public Healthcare Centre 2,702 1.2% 29.7%

15 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 2,674 1.1% 30.9%

16 Polish Red Cross Maritime Hospital in Gdynia 2,604 1.1% 32.0%

17 Specialist Hospital in Brzozów, Bronisław Markiewicz Subcarpathian Oncology Centre 2,474 1.1% 33.0%

18 Fryderyk Chopin Regional Specialist Hospital in Rzeszów 2,426 1.0% 34.1%

19 Maria Skłodowska-Curie Oncology Centre in Białystok 2,388 1.0% 35.1%

20 Oncology Centre of Beskidy - John Paul II Municipal Hospital in Bielsko-Biała 2,224 0.9% 36.0%

21 Public Paediatric Central Clinical Hospital in Warsaw 2168 0.9% 37.0%

22 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 2147 0.9% 37.9%

82 23 Dolnośląskie Centre of Lung Diseases in Wrocław 2126 0.9% 38.8%

24 National Institute of Tuberculosis and Lung Diseases in Warsaw 2101 0.9% 39.7%

25 Saint Luke's Provincial Hospital in Tarnów Independent Public Healthcare Centre - Outpatient Care 2,086 0.9% 40.6%

26 Independent Public Clinical Hospital No. 4 in Lublin 2,008 0.9% 41.4%

27 Wielkopolskie Zeyland Pulmonology and Thoracic Surgery Centre in Poznań 1992 0.8% 42.3%

28 Jan Mikulicz-Radecki University Teaching Hospital in Wrocław 1988 0.8% 43.1%

29 Independent Public Clinical Hospital No. 2 of Pomeranian Medical University in Szczecin 1806 0.8% 43.9%

30 Blessed Virgin Mary’s Regional Specialist Hospital in Częstochowa 1741 0.7% 44.6%

31 Magodent Non-Public Healthcare Centre in Warsaw 1726 0.7% 45.4%

32 Regional Polyclinical Hospital in Elbląg 1720 0.7% 46.1%

Centrum Medyczne Hep Sp. z o.o. Non-Public Healthcare Centre Centrum Medyczne HCP - Inpatient treatment in 33 1716 0.7% 46.8% Poznań

34 Independent Public Healthcare Centre Regional Hospital in Zielona Góra 1690 0.7% 47.5%

35 Professor Alfred Sokołowski Specialist Hospital in Szczecin 1670 0.7% 48.3%

36 Janusz Korczak Regional Specialist Hospital in Słupsk 1656 0.7% 49.0%

37 Independent Public Healthcare Centre - Professor Koszarowski Oncology Centre in Opole 1652 0.7% 49.7%

38 Regional Specialist Hospital in Wrocław 1641 0.7% 50.4%

39 Stanisław Leszczyński Hospital in Katowice 1629 0.7% 51.1%

40 Military Memorial Medical Academy – Central Veterans' Hospital in Łódź 1596 0.7% 51.7%

41 Independent Public Healthcare Centre Provincial Specialist Hospital No. 3 in Rybnik 1582 0.7% 52.4%

42 Ludwik Rydygier Specialist Hospital in Kraków - Hospital Care 1575 0.7% 53.1%

43 Saint Barbara’s Regional Specialist Hospital No. 5 in Sosnowiec 1499 0.6% 53.7%

44 John Paul II Independent Public Provincial Hospital in Zamość 1498 0.6% 54.4%

45 Alfred Sokołowski Specialist Hospital in Wałbrzych 1485 0.6% 55.0%

46 Heliodor Święcicki Clinical Hospital at the Karol Marcinkowski Medical University in Poznań 1484 0.6% 55.6%

47 4 Military Clinical Hospital with Specialist Outpatient Clinic Independent Public Healthcare Centre in Wrocław 1475 0.6% 56.2%

48 John Paul II Specialist Hospital in Kraków – Hospital Wards 1467 0.6% 56.9%

49 Regional Polyclinical Hospital in Konin 1446 0.6% 57.5%

50 Professor Michałowski Non-Public Healthcare Centre Specialist Hospital in Katowice 1422 0.6% 58.1%

51 Karol Marcinkowski University Hospital of Lord’s Transfiguration in Poznań 1416 0.6% 58.7%

52 Maria Skłodowska-Curie Regional Specialist Hospital in Zgierz 1385 0.6% 59.3%

53 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre 1334 0.6% 59.9%

54 M. Kopernik Voivodeship Hospital in Koszalin 1334 0.6% 60.4%

55 Ludwik Rydygier Regional Polyclinic Hospital in Toruń 1325 0.6% 61.0%

56 Medical University of Bialystok Clinical Hospital 1301 0.6% 61.5%

57 Mazovian Specialist Hospital in Radom 1277 0.5% 62.1%

58 Regional Polyclinical Hospital in Płock 1274 0.5% 62.6%

59 Infant Jesus Clinical Hospital in Warsaw 1244 0.5% 63.2%

Józef Struś Multidisciplinary City Hospital with Care and Curative Institution Independent Public Healthcare Centre located 60 in Poznań, Szwajcarska St. 3 1226 0.5% 63.7%

61 Independent Public Healthcare Centre Regional Specialist Hospital No. 4 in Bytom 1214 0.5% 64.2%

62 Kotlina Jelenionórska Regional Hospital Centre 1192 0.5% 64.7%

63 Gabriel Narutowicz Specialist City Hospital in Kraków. 1178 0.5% 65.2%

64 St. Adalbert Specialist Hospital Independent Public Healthcare Centre in Gdańsk 1178 0.5% 65.7%

65 Regional Specialist Hospital in Legnica 1176 0.5% 66.2%

66 St. Raphael Regional Specialist Hospital in Czerwona Góra 1176 0.5% 66.7%

67 Wielospecjalistyczny Szpital Wojewódzki w Gorzowie Wlkp. Spółka z Ograniczoną Odpowiedzialnością 1160 0.5% 67.2%

68 Nikolay Pirogov Regional Specialist Hospital in Łódź 1120 0.5% 67.7%

69 Specialist Mother and Child Healthcare Complex in Poznań 1119 0.5% 68.2%

70 Independent Public Clinical Hospital No. 4 in Lublin 1096 0.5% 68.6%

71 Pulmonology and Thoracic Surgery Centre in Bystra 1090 0.5% 69.1%

72 Mazovian Center for Treatment of Lung Diseases and Tuberculosis 1083 0.5% 69.5%

83 73 Cardinal Stefan Wyszyński Regional Specialist Hospital Independent Public Healthcare Centre in Lublin 1073 0.5% 70.0%

74 Regional Complex of Healthcare Facilities, Centre for Treatment of Lung Diseases and Rehabilitation in Łódź 1070 0.5% 70.5%

75 Florian Ceynowa Specialist Hospital in Wejherowo 1038 0.4% 70.9%

76 Specialist Hospital in Siedlce 1021 0.4% 71.3%

77 Międzylesie Specialist Hospital in Warsaw 1016 0.4% 71.8%

78 Specialist Hospital in Kościerzyna 1007 0.4% 72.2%

79 Dr Antoni Jurasz University Hospital No. 1 in Bydgoszcz 984 0.4% 72.6%

80 Władysław Biegański Regional Specialist Hospital in Grudziądz 966 0.4% 73.0%

81 Independent Public Complex of Tuberculosis and Lung Diseases in Olsztyn 962 0.4% 73.4%

82 Professor Kornel Gibiński Central Clinical Hospital No. 7 of the Silesian Medical University in Katowice 959 0.4% 73.8%

83 Municipal Polyclinical Hospital in Olsztyn 948 0.4% 74.2%

84 Regional Complex of Healthcare Facilities, Centre for Treatment of Lung Diseases and Rehabilitation in Łódź 939 0.4% 74.6%

85 Regional Specialist Hospital No. 2 in Jastrzębie-Zdrój 930 0.4% 75.0%

86 Independent Public Regional Polyclinical Hospital in Szczecin 926 0.4% 75.4%

87 Affidea Onkoterapia Spółka z Ograniczoną Odpowiedzialnością in Koszalin 924 0.4% 75.8%

88 Hospital Treatment Centre in Nowy Sącz 903 0.4% 76.2%

89 Józef Psarski Mazovian Specialist Hospital in Ostrołęka 887 0.4% 76.6%

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in 90 Warsaw 867 0.4% 77.0%

91 Independent Public Healthcare Centre of the Ministry of Internal Affairs in Łódź 863 0.4% 77.3%

92 Jędrzej Śniadecki Independent Public Healthcare Centre Regional Hospital in Białystok 854 0.4% 77.7%

93 Jan Biziel University Hospital No. 2 in Bydgoszcz 850 0.4% 78.1%

94 Polyclinic of Bródno Clinical Centre in Warsaw 849 0.4% 78.4%

95 Regional Specialist Hospital in Ciechanów 840 0.4% 78.8%

96 Kujawsko-Pomorskie Pulmonology Center in Bydgoszcz 840 0.4% 79.1%

97 Norbert Barlicki Independent Public Healthcare Centre University Clinical Hospital No. 1 at the Łódź Medical University 832 0.4% 79.5%

98 Sosnowiecki Szpital Miejski Spółka z Ograniczoną Odpowiedzialnością 832 0.4% 79.8%

TOTAL: 234,880 100.0% Source: compiled by DAiS based on data provided by the NFZ.

Geographical distribution of hospitals treating 80% of cancer patients (cf. Table 8) is shown with an accuracy to a county in Figure 96. The analysed hospitals are located mainly either in city counties or in counties adjacent to them. Of 98 hospitals, 11 were located in Warsaw, 7 in Poznań, 6 in Łódź, 5 in Kraków and 5 in Wrocław. This means that every third hospital listed in Table 8 was located in one of these five cities.

18 out of 98 hospitals treating the largest number of cancer patients in Poland were located in Mazowieckie Voivodeship. Eleven were located in Warsaw, while Ostrołęka, Płock, Radom, Siedlce and the counties of Ciechanów, Legionowo and Otwock each had one.

84 Figure 96: Hospitals jointly treating approx. 80% of all cancer patients (2012)

Number of hospitals

No hospital 1 (2-4) (4-6) (6-11)

Source: compiled by DAiS based on data provided by the NFZ.

Another aspect of the cancer treatments provided analysed related to repeated hospitalisations, expressed as the average number of hospitalisations per one cancer patient in individual voivodeships. Figure 9710compares individual voivodeships in terms of repeated hospitalisations.

Figure 97: Average number of hospitalisations per one patient in voivodeships (2012)

Source: compiled by DAiS based on data provided by the NFZ.

In 2012, in Poland, there was an average of 2.32 hospitalisations per one cancer patient. The highest average number of hospitalisations per patient was recorded in the Łódzkie Voivodeship (2.73). In turn, the lowest number was reported in Świętokrzyskie (1.99) and Pomorskie (1.85) Voivodeships. In Mazowieckie Voivodeship, there were on average 2.11 hospitalisations per patient in 2012, i.e. below the Polish average.

10 The Figure also includes chemotherapy and radiotherapy hospitalisations.

85 2.1.2 Healthcare providers in the voivoideship

In Mazowieckie Voivodeship in 2012, hospital cancer treatments were provided by 103 hospitals.The geographical distribution of these in the Voivodeship under analysis is shown in Figure 98. The values on the map indicate the number of service providers in a county. As it may be seen, the counties with the largest number of healthcare providers treating cancer patients are concentrated in the centre of the Voivodeship or in its southern part. The largest number (42) of service providers had their facilities in Warsaw. Six facilities were located in Radom, and another six in Otwock County. In Siedlce and the counties of Pruszków, Wołomin and Wyszków each, there were three hospitals treating patients with a cancer diagnosis.

Figure 98: Counties with hospitals treating cancer patients (2012)

Source: compiled by DAiS based on data provided by the NFZ.

Table 9 lists all facilities in Mazowieckie Voivodeship to account for oncology-related services in 2012. Theyare ranked by the number of cancer patients admitted. 19 hospitals are highlighted, in which the share of cancer patients regionwide exceeded 2%11. The facilities more analysed in greater detail hereinbelow.

11 The percentage of patients on a regional scale is defined as the number of patients admitted with a cancer diagnosis analysed versus the unique number of cancer patients in a voivodeship. Accordingly, the sum of this variable is greater than 100%. This is because a patient admitted to two different hospitals will be included in the numerator in each of them, but only once in the nominative.

86 Table 9: Hospitals in Mazowieckie Voivodeship settling oncology-related services with the NFZ (2012)

Item Name of the treatment provider Number of Percenta patients ge of patients

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw 11324 28.4% 2 Military Institute of Medicine in Warsaw 2942 7.4% 3 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 2,674 6.7% 4 Public Paediatric Central Clinical Hospital in Warsaw 2168 5.4% 5 Central Clinical Hospital of the Ministry of the Interior and Administration in 2147 5.4% Warsaw 6 National Institute of Tuberculosis and Lung Diseases in Warsaw 2101 5.3% 7 Magodent Non-Public Healthcare Centre in Warsaw 1726 4.3% 8 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre 1334 3.3% 9 Mazovian Specialist Hospital in Radom 1277 3.2% 10 Regional Polyclinical Hospital in Płock 1274 3.2% 11 Infant Jesus Clinical Hospital in Warsaw 1244 3.1% 12 Mazovian Center for Treatment of Lung Diseases and Tuberculosis 1083 2.7% 13 Specialist Hospital in Siedlce 1021 2.6% 14 Międzylesie Specialist Hospital in Warsaw 1016 2.5% 15 Józef Psarski Mazovian Specialist Hospital in Ostrołęka 887 2.2% 16 Professor Witold Orłowski Independent Public Clinical Hospital of the Medical 867 2.2% Centre for Postgraduate Education in Warsaw 17 Polyclinic of Bródno Clinical Centre 849 2.1% 18 Regional Specialist Hospital in Ciechanów 840 2.1% 19 John Paul II Independent Public Specialist Western Hospital in Grodzisk 831 2.1% Mazowiecki 20 Fryderyk Chopin European Health Centre 798 1.9% 21 Tytus Chałubiński Specialist Hospital in Radom 668 1.7% 22 Transfiguration Hospital in Warsaw Independent Public Healthcare Centre 498 1.2% 23 Czerniakowski Hospital Independent Public Healthcare Centre 490 1.2% 24 Anna Gostyńska Wola Hospital Independent Public Healthcare Centre 424 1.1% 25 Włodzimierz Roefler Railway Hospital in Pruszków – Independent Public 417 1.0% Healthcare Centre 26 “Attis” Therapeutic, Rehabilitation and Occupational Medicine Centre 386 1.0% 27 Holy Family Specialist Hospital Independent Public Healthcare Centre 361 0.9% 28 Rafał Masztak Grochów Hospital Independent Public Healthcare Centre 279 0.7% 29 Józef Piłsudski Independent Public Complex of Healthcare Facilities in Płońsk 270 0.7% 30 Independent Public Complex of Healthcare Facilities in Kozienice 248 0.6% 31 Teodor Dunin Independent Specialist Healthcare Complex 247 0.6%

87 32 St. Anne Non-Public Healthcare Centre in Piaseczno 244 0.6% 33 Institute of Psychiatry and Neurology 240 0.6% 34 Specialist Hospital/Specialist Outpatient Clinic and Emergency Medical Service 229 0.6% Centre 35 Princess Anna Mazowiecka Public Teaching Hospital 226 0.6% 36 Wołomin County Hospital – Independent Complex of Public Healthcare Facilities 204 0.5% 37 Independent Public Healthcare Centre in Gostynin 204 0.5% 38 Independent Public Healthcare Centre in Sokołów Podlaski 202 0.5% 39 Sochaczew County Hospital Healthcare Complex 172 0.4% 40 Independent Public Complex of Healthcare Facilities in Przasnysz 172 0.4% 41 St. Anne's Provincial Hospital of Trauma Surgery Independent Public 156 0.4% Healthcare Centre 42 Centrum Zdrowia Mazowsza Zachodniego Spółka z Ograniczoną 161 0.4% Odpowiedzialnością 43 Independent Public Healthcare Centre in Garwolin 149 0.4% 44 “Płocki ZOZ” Non-Public Healthcare Centre 140 0.4% 45 Obstetrics and Gynaecology Clinic latros Andrzej Ostaszewski Non-Public 140 0.4% Healthcare Centre 46 Independent Public Complex of Healthcare Facilities in Pruszków 138 0.3% 47 Independent Public Healthcare Complex 138 0.3% 48 Independent Public Healthcare Centre in Mława 135 0.3% 49 Independent Public Healthcare Centre in Pułtusk 129 0.3% 50 “Ibis” Day Hospital Non-Public Healthcare Centre 124 0.3% 51 Independent Public Healthcare Centre in Siedlce 123 0.3% 52 Danish Red Cross Independent Public Healthcare Centre ZZLO 119 0.3% 53 Independent Public Complex of Healthcare Facilities in Wyszków 117 0.3% 54 Independent Public Healthcare Centre in Węgrów 116 0.3% 55 Complex of Public Healthcare Facilities in Otwock 114 0.3% 56 Medicover Hospital 110 0.3% 57 Independent Public Healthcare Centre in Nowe Miasto Nad Pilicą 109 0.3% 58 Independent Public Complex of Healthcare Facilities in Sierpc 108 0.3% 59 Nowy Dwór Medical Centre in Nowy Dwór Mazowiecki 91 0.2% 60 Mazovia Hospital Non-Public Healthcare Centre 88 0.2% 61 Szpital Solec Spółka z Ograniczoną Odpowiedzialnością 84 0.2% 62 One Day Surgery Complex "Medica" 82 0.2% 63 Institute of Mother and Child 81 0.2% 64 Independent Public Complex of Healthcare Facilities 78 0.2% 65 Independent Public Complex of Healthcare Facilities in Pionki 58 0.2% 66 Independent Public Complex of Healthcare Facilities in Ostrów Mazowiecka 65 0.2% 67 Independent Public Healthcare Centre 61 0.2% 68 Independent Public Healthcare Centre Warszawa-Ursynów 60 0.2% 69 Endoterapia Sp. z o.o. 59 0.1% 70 Independent Public Complex of Healthcare Facilities in Lipsko 58 0.1% 71 Independent Public Complex of Healthcare Facilities – Iłża Hospital 56 0.1%

88 72 Institute of Hematology and Transfusion Medicine 49 0.1% 73 Jolly Med Spółka z Ograniczoną Odpowiedzialnością 41 0.1% 74 Independent Public Complex of Healthcare Facilities in Przysucha 40 0.1% 75 Polmedic Spółka z Ograniczoną Odpowiedzialnością 32 0.1% 76 Centrum Medyczne "Żelazna" Spółka z Ograniczoną Odpowiedzialnością 31 0.1% 77 Professor Jan Mazurkiewicz Mazovian Specialist Healthcare Centre in 30 0.1% Pruszków 78 Powiatowe Centrum Zdrowia Spółka z Ograniczoną Odpowiedzialnością 26 0.1% 79 Children’s Memorial Health Institute in Warsaw 24 0.1% 80 Battle of Warsaw 1920 Medical Centre in Radzymin – Independent Public 23 0.1% Complex of Healthcare Facilities 81 Medicon Sp. z o.o. 23 0.1% 82 Independent Public Complex of Healthcare Facilities in Zwoleń 22 0.1% 83 Inflancka Specialist Hospital in Warsaw Independent Public Healthcare Centre 21 0.1% 84 Professor Adam Gruca Independent Public Clinical Hospital of the Medical 12 0.0% Centre for Postgraduate Education 85 Endoterapia Pfg Healthcare Centre 12 0.0% 86 Professor Weiss Hospital 10 0.0% 87 Cardinal Wyszyński Institute of Cardiology 9 0.0% 38 Military Institute of Aviation Medicine 8 0.0% 89 Family Health Centre 8 0.0% 90 Swissmed Health Centre 7 0.0% 91 Arion Med Spółka z Ograniczoną Odpowiedzialnością 7 0.0% 92 Centrum Medyczne Damiana Sp. z o.o. 7 0.0% 93 Jerzy Petz Mediq Non-Public Healthcare Centre 5 0.0% 94 Independent Public Healthcare Centre Regional Hospital for Infectious 3 0.0% Diseases in Warsaw 95 Public Paediatric Central Clinical Hospital in Warsaw 2 0.0% 96 Niepubliczny Zakład Opieki Zdrowotnej "Gin-Med" Sp. z o.o. 2 0.0% 97 Eleonora Reicher Institute of Rheumatology 1 0.0% 98 Family and Specialist Medicine Centre Non-Public Healthcare Centre 1 0.0% 99 Starówka Healthcare Centre 1 0.0% 100 Niepubliczny Zakład Opieki Zdrowotnej Ginmedico Sp. z o.o. 1 0.0% 101 Niepubliczny Zakład Opieki Zdrowotnej Gin-Medicus Sp. z o.o. 1 0.0% 102 Warsaw Medical Center, Warszawskie Centrum Medyczne Spółka z 1 0.0% Ograniczoną Odpowiedzialnością 103 Niepubliczny Zakład Opieki Zdrowotnej "Nel-Med" Jarosław Janas Piotr Wasiak 1 0.0% Spółka Jawna TOTAL (unique patients in the voivodeship): 39907 100.0% Source: compiled by DAiS based on data provided by the NFZ.

The analysis of hospitals in Mazowieckie Voivodeship that account for cancer-related services (Table 9) demonstrates that Maria Skłodowska-Curie Institute of Oncology admitted 11,324 patients with cancer-related diseases, i.e. more than 28% of patients from the Voivodeship.

89 The next institution in terms of the number of patients, the Military Institute of Medicine, admitted almost 3,000 patients, that is over 7% of patients from the Voivodeship.

More than 5% of patients with a cancer diagnosis from the Voivodeship were also hospitalised at "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew, Independent Public Central Clinical Hospital, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw and at the National Institute of Tuberculosis and Lung Diseases.

The location of healthcare service providers treating most patients with cancer-related diseases is shown in Figure 99. Based on the analysis of the map, it was found that 11 of them are located in Warsaw. Moreover, cities with county rights, i.e. Ostrołęka, Płock, Radom and Siedlce as well as the counties of Ciechanów, Grodzisk Mazowiecki, Legionowo and Otwock, each had one.

90 Figure 99: Counties with hospitals treating over 2% of cancer patients regionwide (2012)

Source: compiled by DAiS based on data provided by the NFZ.

The map shown in Figure 100 provides information on the migration of cancer patients to Mazowieckie Voivodeship. Most patients come to Warsaw, and rightly, since almost half of the facilities treating cancer patients, including the largest regional hub, are located in the city. Many patients move also to other city counties as well as to the counties of Grodzisk Mazowiecki and Otwock where the hospitals treating a significant number of cancer patients are situated. Patients from counties located in the north of the Voivodeship also chose the county of Ciechanów. In turn, more than 10% of patients from the county of Lipsko went to Ostrowiec Świętokrzyski (Świętokrzyskie Voivodeship), and more than 25% from the county of Szydłowiec to Kielce (Świętokrzyskie Voivodeship).

91 Figure 100: Migrations of cancer patients between counties within Mazowieckie Voivodeship (2012)

Share (%) of patients from the county Share (%) of hospitalised patients admitted to hospitals in the county

Source: compiled by DAiS based on data provided by the NFZ.

Figure 101 shows patients from other voivodeships (those from which patients represented at least 5% of all incoming patients) coming to Mazowieckie Voivodeship. 86% of cancer patients hospitalised in Mazowieckie Voivodeship came from this Voivodeship, which means that many people came from other regions of Poland. Most patients from outside the Voivodeshipcame from Lubelskie Voivodeship. Cancer patients also migrated to a large extent from Podlaskie, Łódzkie, Warmińsko-Mazurskie and Świętokrzyskie Voivodeships.

Figure 101: Cancer patients migrating to Mazowieckie Voivodeship (2012)

789 patients 384 patients 901 patients

935 patients

1145 patients

Share (%) of patients 373 patients from other voivodeships 415 patients

445 patients

Share (%) of patients from the voivodeship

Source: compiled by DAiS based on data provided by the NFZ.

92 Figure 102 shows migrations of cancer patients leaving Mazowieckie Voivodeship and receiving treatment in other voivodeships. Only 4% of patients from Mazowieckie Voivodeship chose to receive treatment outside of the Voivodeship. Most of them went to Świętokrzyskie Voivodeship.

Figure 102: Cancer patients migrating from Mazowieckie Voivodeship (2012)

patients

patients patients

patients Patients treated outside patients the voivodeship patients

Share (%) of patients treated outside the voivodeship Source: compiled by DAiS based on data provided by the NFZ.

2.1.3 Analysis of selected healtcare service providers

Further analysis included healthcare providers who treated more than 2% of cancer patients regionwide.

The first aspect to be analysed in selected hospitals was the share of patients from outside the voivodeship in relation to all cancer patients treated in the hospital. Relevant data are included in Table 10. In the first six hospitals in terms of the number of cancer patients treated, apart from "Zdrowie" Medical Centre in Wieliszew, the share of patients from outside the voivodeship is very high, from 20% to 30%.

Table 10: Share of patients from outside the voivodeship among cancer patients by healthcare service provider (2012)

Percentage of Item Name of the treatment provider patients from other regions

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw 22.2%

2 Military Institute of Medicine in Warsaw 25.1%

3 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 7.0%

4 Public Paediatric Central Clinical Hospital in Warsaw 29.8

93 5 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 20.5%

6 National Institute of Tuberculosis and Lung Diseases in Warsaw 24.2%

7 Magodent Non-Public Healthcare Centre in Warsaw 10.7%

8 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre 4.1%

9 Mazovian Specialist Hospital in Radom 1.7%

10 Regional Polyclinical Hospital in Płock 3.8%

11 Infant Jesus Clinical Hospital in Warsaw 8.6%

12 Mazovian Center for Treatment of Lung Diseases and Tuberculosis 5.1%

13 Specialist Hospital in Siedlce 13.6%

14 Międzylesie Specialist Hospital in Warsaw 5.3%

15 Józef Psarski Mazovian Specialist Hospital in Ostrołęka 16.4%

16 Professor Witold Orłowski Medical Centre for Postgraduate Education in Warsaw 6.4%

17 Polyclinic of Bródno Clinical Centre 6.5%

18 Regional Specialist Hospital in Ciechanów 1.9%

19 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki 9.4% Source: compiled by DAiS based on data provided by the NFZ.

The average number of hospitalisations per one patient was then analysed. Figure 10312shows data on 19 largest facilities in Mazowieckie Voivodeship.

There were 2.11 hospitalisations per patient on average in Mazowieckie Voivodeship. The above-mentioned rate was the highest for "Magodent" Mon-Public Healthcare Facility (2.6), Mazovian Center for Treatment of Lung Diseases and Tuberculosis in Otwock (2.53), Mazovian Specialist Hospital in Radom (2.39), Military Institute of Medicine (2.29) and Specialist Hospital in Siedlce (2.28). In Maria Skłodowska-Curie Institute of Oncology, i.e. the facility treating most cancer patients, the number of hospitalisations per patient was 1.86.

12 The Figure also includes chemotherapy and radiotherapy hospitalisations.

94 Figure 103: The average number of hospitalisations per patient in individual hospitals (2012)

number of hospitalisations/ Item Name of the treatment provider patients patient

1 Magodent Non-Public Healthcare Centre 1726 2.6

2 Mazovian Center for Treatment of Lung Diseases and Tuberculosis 1083 2.53

3 Mazovian Specialist Hospital in Radom 1277 2.39

4 Military Institute of Medicine 2942 2.29

5 Specialist Hospital in Siedlce 1021 2.28

6 Regional Specialist Hospital in Ciechanów 840 1.88

7 Maria Skłodowska-Curie Institute of Oncology 11324 1.85

Central Clinical Hospital of the Ministry of the Interior and Administration in 8 2147 1.77 Warsaw

9 Regional Polyclinical Hospital in Płock 1274 1.74

10 Public Paediatric Central Clinical Hospital 2158 1.7

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew/Clinic of the 11 2,674 1.68 Oncology Hospital in Wieliszew

12 Infant Jesus Clinical Hospital 1244 1.51

13 Polyclinic of Bródno Clinical Centre 849 1.51

14 John Paul II Independent Public Specialist Western Hospital 831 1.6

15 Międzylesie Specialist Hospital in Warsaw 1015 1.55

16 Józef Psarski Mazovian Specialist Hospital in Ostrołęka 887 1.54

17 Institute of Tuberculosis and Lung Diseases 2101 1.53

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical 18 857 1.48 Centre for Postgraduate Education in Warsaw

19 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre 1334 1.38 Source: compiled by DAiS based on data provided by the NFZ.

95 The next stage of the analysis consisted in verifying to what wards the patients are admitted in previously selected 19 hospitals with the largest number of patients admitted for cancer- related treatment (Figure 104). Patients were most often hospitalised at wards of oncology (6,784), urology (6,474) and oncological surgery (5,659).

Figure 104: Number of cancer patients in wards of particular hospitals (2012)

Oncology ward Urology ward Oncological surgery ward Surgical ward Radiotherapy ward Thoracic surgery ward Lung diseases ward Internal diseases ward Nuclear medicine ward Tuberculosis and lung diseases ward Gastroenterology ward Otorhinolaryngology ward Clinical oncology/Chemotherapy ward Neurosurgery ward Maxillo-facial surgery ward Endocrinology ward Obstetrics and gynaecology ward Neurology ward Haematology ward Gynaecology ward Oncological gynaecology ward

Source: compiled by DAiS based on data provided by the NFZ.

Table 11 and Table 1213 show the number of hospitalised patients in particular wards in the hospitals analysed. The first table contains data expressed in absolute values, while in the other one it is presented as a percentage (a percentage of all cancer patients in a given hospital).

Based on the analysis of Table 11 and Table 12, it was found that cancer patients in the radiotherapy ward were reported in 2 facilities. Only in one hospital they were admitted to the clinical oncology/chemotherapy ward. In addition, in two hospitals, such patients were treated in the nuclear medicine ward. As it can be seen, in many hospitals relatively many patients were treated in urology wards. Two hospitals (the National Institute of Tuberculosis and Lung Diseases in Warsaw and the Mazovian Centre for Treatment of Lung Diseases and Tuberculosis in Otwock) admitted almost all of their patients to thoracic surgery ward, lung diseases ward, or tuberculosis and lung diseases ward.

13 The number of unique patients does not equal the sum of cases treated in wards, as one patient could be treated in several wards during one year.

96 Table 11: Number of cancer patients in particular hospitals by ward (2012)

Healthcare provider/Ward name

facial surgery ward surgery facial

Surgical ward Surgical ward surgery Thoracic ward surgery Oncological Maxillo ward Neurosurgery ward diseases Internal ward Endocrinology ward Gastroenterology ward Haematology ward medicine Nuclear ward Neurology ward diseases lung and Tuberculosis ward diseases Lung ward gynaecology and Obstetrics ward Gynaecology ward Otorhinolaryngological ward Urology ward gynaecology Oncological ward Oncology ward oncology/chemotherapy Clinical ward Radiotherapy Other TOTAL patients Unique

3,43 67 3,90 Maria Skłodowska-Curie Institute of Oncology in Warsaw 668 292 278 4 1080 474 1712 674 13193 11324 9 1 1

Military Institute of Medicine in Warsaw 612 49 69 433 169 5 62 196 173 92 386 1091 80 3,417 2,942

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 26 587 586 220 1623 3,042 2,674

Public Paediatric Central Clinical Hospital in Warsaw 677 552 108 331 23 10 3 28 178 216 269 40 2435 2168

Central Clinical Hospital of the Ministry of the Interior and 442 85 226 83 395 98 23 73 36 593 397 2451 2147 Administration in Warsaw

National Institute of Tuberculosis and Lung Diseases in Warsaw 1674 552 1 2,227 2101

Magodent Non-Public Healthcare Centre in Warsaw 984 84 75 870 4 2017 1726

Jerzy Popiełuszko Bielański Hospital – Independent Public 140 80 147 50 218 39 ? 84 506 7 1382 1334 Healthcare Centre

Mazovian Specialist Hospital in Radom 236 26 98 46 471 36 43 454 1410 1277

Regional Polyclinical Hospital in Płock 367 2 94 59 229 73 84 337 105 25 1375 1274

Infant Jesus Clinical Hospital in Warsaw 105 75 29 42 960 40 1251 1244

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 4 298 22 884 1208 1083

Specialist Hospital in Siedlce 59 39 31 28 62 321 549 3 1092 1021

Międzylesie Specialist Hospital in Warsaw 69 193 17 48 5 46 666 13 1057 1016

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 90 97 117 43 134 45 72 351 7 956 887

Professor Witold Orłowski Independent Public Clinical Hospital of 136 33 44 45 588 24 870 867 the Medical Centre for Postgraduate Education in Warsaw

Polyclinic of Bródno Clinical Centre 130 126 120 158 59 135 138 67 3 936 849

Regional Specialist Hospital in Ciechanów 129 137 28 144 26 59 250 195 1 969 840

John Paul II Independent Public Specialist Western Hospital in 136 23 219 38 456 3 875 831 Grodzisk Mazowiecki Source: compiled by DAiS based on data provided by the NFZ.

Table 12: Share of cancer patients in particular hospitals by ward (2012)

Healthcare provider/Ward name

facial surgery ward surgery facial

rnal diseases ward diseases rnal

Otorhinolaryngology ward Otorhinolaryngology

Surgical ward Surgical ward surgery Thoracic ward surgery Oncological Maxillo ward Neurosurgery Inte ward Endocrinology ward Gastroenterology ward Haematology ward medicine Nuclear ward Neurology ward diseases lung and Tuberculosis ward diseases Lung ward gynaecology and Obstetrics ward Gynaecology ward Urology ward gynaecology Oncological ward Oncology ward oncology/Chemotherapy Clinical ward Radiotherapy Other Maria Skłodowska-Curie Institute of Oncology in Warsaw 5% 26% 5% 2% 2% 8% 4% 30% 13% 5%

Military Institute of Medicine in Warsaw 18% 1% 2% 13% 5% 2% 6% 5% 3% 11% 32% 2%

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 1% 19% 19% 7% 53%

Public Paediatric Central Clinical Hospital in Warsaw 28% 23% 4% 14% 1% 1% 7% 9% 11% 2%

Central Clinical Hospital of the Ministry of the Interior and 18% 4% 9% 3% 16% 4% 1% 3% 2% 24% 16% Administration in Warsaw

National Institute of Tuberculosis and Lung Diseases in Warsaw 75% 25%

Magodent Non-Public Healthcare Centre in Warsaw 49% 4% 4% 43%

Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare 10% 6% 11% 4% 16% 3% 8% 6% 37% Centre in Warsaw

Mazovian Specialist Hospital in Radom 17% 2% 7% 3% 33% 3% 3% 32%

97 Regional Polyclinical Hospital in Płock 27% 7% 4% 17% 5% 6% 25% 8% 2%

Infant Jesus Clinical Hospital in Warsaw 5% 6% 2% 3% 77% 3%

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 25% 2% 73%

Specialist Hospital in Siedlce 5% 4% 3% 3% 6% 29% 50%

Międzylesie Specialist Hospital in Warsaw 7% 18% 2% 5% 4% 63% 1%

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 9% 10% 12% 5% 14% 5% 8% 37% 1%

Professor Witold Orłowski Independent Public Clinical Hospital of the 16% 4% 5% 5% 68% 3% Medical Centre for Postgraduate Education in Warsaw

Polyclinic of Bródno Clinical Centre 14% 14% 13% 17% 6% 14% 15% 7%

Regional Specialist Hospital in Ciechanów 13% 14% 3% 15% 3% 6% 26% 20%

John Paul II Independent Public Specialist Western Hospital in 16% 3% 25% 4% 52% Grodzisk Mazowiecki Source: compiled by DAiS based on data provided by the NFZ.

Figure 105 shows the number of beds in Mazowieckie Voivodeship in previously listed treatment facilities. Most beds are located in internal diseases, general surgery and obstetric and gynecology wards. It should be noted, however, that not only cancer patients are hospitalised in these wards. As regards wards dedicated to cancer patients, there were most beds in oncology wards. In Figure 106, the values are given per 100,000 people. Table 13 shows the number of beds in these wards in the 19 largest hospitals treating cancer patients.

98 Figure 105: Number of beds in wards [as of 30 June 2012]

Internal diseases ward Surgical ward Obstetrics and gynaecology ward Gastroenterology ward Neurology ward Urology ward Lung diseases ward Clinical oncology/Chemotherapy ward Tuberculosis and lung diseases ward Neurosurgery ward Haematology ward Gastroenterology ward Oncological surgery ward Gynaecology ward Endocrinology ward Maxillo-facial surgery ward Thoracic surgery ward Radiotherapy ward Oncological gynaecology ward Clinical oncology/Chemotherapy ward Nuclear medicine ward

Source: compiled by DAiS based on data provided by the NFZ and the Register of Entities Offering

Therapeutic Services (RPWDL)

Figure 106: Number of beds in wards per 100,000 people [as at 30 June 2012]

Source: compiled by DAiS based on data provided by the NFZ and the Register of Entities Offering

Therapeutic Services (RPWDL)

99 Table 13: Number of beds in particular hospitals by ward [as of 30 June 2012]

Healthcare provider/Ward name

ward

facial surgery ward surgery facial

Neurosurgery ward Neurosurgery ward Gastroenterology ward Haematology

Surgical ward Surgical ward surgery Thoracic ward surgery Oncological Maxillo ward diseases Internal ward Endocrinology ward medicine Nuclear ward Neurology ward diseases lung and Tuberculosis ward diseases Lung ward gynaecology and Obstetrics ward Gynaecology ward Otorhinolaryngology ward Urology ward gynaecology Oncological Oncology ward oncology/Chemotherapy Clinical ward Radiotherapy Maria Skłodowska-Curie Institute of Oncology 25 137 35 24 13 30 50 10 18 241 90

Military Institute of Medicine 75 3 43 12 41 26 35 34 32 34 30 56

Public Paediatric Central Clinical Hospital 118 23 41 136 25 64 110 45 45 114 14

Central Clinical Hospital of the Ministry of the Interior and Administration 40 16 4 32 65 27 2 15 13 15 28 34 in Warsaw

Institute of Tuberculosis and Lung Diseases 76 172

Magodent Non-Public Healthcare Centre 1 14 1 2 8 1 3 2 6

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew/Clinic of the 2 2 16 15 2 10 14 Oncology Hospital in Wieliszew

Jerzy Popiełuszko Bielański Hospital – Jerzy Popiełuszko Bielański 43 40 47 22 24 22 75 24 25 Hospital – Independent Public Healthcare Centre

Mazovian Specialist Hospital in Radom 67 34 84 26 72 94 26 42

Regional Polyclinical Hospital in Płock 95 16 76 35 61 80 31 31 32

Infant Jesus Clinical Hospital 22 64 4 16 18 16 60

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 3 20 27 319

Specialist Hospital in Siedlce 28 33 20 26 28 33 31

Międzylesie Specialist Hospital in Warsaw 35 99 6 21 10 30 20 37

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 43 10 62 5 22 21 57 15 26 4

Professor Witold Orłowski Independent Public Clinical Hospital of the 63 30 14 23 25 Medical Centre for Postgraduate Education in Warsaw

Polyclinic of Bródno Clinical Centre 33 41 59 30 16 65 35 8 6

Regional Specialist Hospital in Ciechanów 30 5 61 4 7 6 16 35 64 40 22 10

John Paul II Independent Public Specialist Western Hospital 30 21 4 25 36 12 8 20 Source: compiled by DAiS based on data provided by the NFZ.

100 Table 14: Number of hospitalised patients in particular hospitals by scope of treatment (2012)

to 1, to to 2 1, to

–

hospitalisation hospitalisation ref. hospitalisation ref.

– –

alisation

Healthcare provider/Scope of treatment

hospitalisation

hospit

–

hospitalisation

hospitalisation hospitalisation

hospitalisation hospitalisation with combined

hospitalisation planned hospitalisation

–

– hospitalisation

–

– –

hospitalisation

– –

hospitalisation

–

hospitalisation

–

hospitalisation

–

cology cology

hospitalisation

–

facial surgery surgery facial patients

Brachytherapy Chemotherapy treatment surgery Thoracic surgery Thoracic surgery General surgery General surgery Oncological Maxillo diseases Lung diseases Internal Endocrinology Gastroenterology Neurosurgery Neurology on Clinical Otolaryngology Obstetrics and gynaecology II level Obstetrics and gynaecology III level Teleradiotherapy therapy Isotope Urology Other TOTAL Unique 3,73 2,39 Maria Skłodowska-Curie Institute of Oncology in Warsaw 890 2267 535 193 35 56 152 278 292 317 837 947 474 568 13,966 11324 2 3 Military Institute of Medicine in Warsaw 661 172 456 49 192 50 433 169 69 62 822 92 386 208 3,821 2942

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 217 178 26 587 71 1530 586 3195 2,674

Public Paediatric Central Clinical Hospital in Warsaw 153 697 552 159 331 23 10 108 28 221 216 42 2,540 2168 Central Clinical Hospital of the Ministry of the Interior and 281 355 435 98 79 85 23 145 36 73 98 593 221 2,522 2147 Administration in Warsaw National Institute of Tuberculosis and Lung Diseases in Warsaw 198 1131 692 518 1 2,540 2101

Magodent Non-Public Healthcare Centre in Warsaw 544 349 754 551 113 2,311 1726 Jerzy Popiełuszko Bielański Hospital – Independent Public 140 147 50 218 80 39 84 111 506 7 1382 1334 Healthcare Centre in Warsaw Mazovian Specialist Hospital in Radom 516 236 448 88 10 26 46 148 43 36 1597 1277

Regional Polyclinical Hospital in Płock 126 367 214 98 2 59 84 73 337 21 1381 1274

Infant Jesus Clinical Hospital in Warsaw 105 75 29 42 960 40 1251 1244

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 290 220 97 4 847 22 1480 1083

Specialist Hospital in Siedlce 287 59 39 31 427 62 28 321 3 1257 1021

Międzylesie Specialist Hospital in Warsaw 69 193 17 48 46 5 666 13 1057 1016

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 90 97 134 117 43 72 45 351 7 956 887 Professor Witold Orłowski Independent Public Clinical Hospital of the 136 33 44 45 588 24 870 867 Medical Centre for Postgraduate Education in Warsaw Polyclinic of Bródno Clinical Centre 67 130 120 158 126 59 138 135 3 936 849

Regional Specialist Hospital in Ciechanów 195 129 144 137 28 59 26 250 1 969 840 John Paul II Independent Public Specialist Western Hospital in 136 219 23 38 456 3 875 831 Grodzisk Mazowiecki Source: compiled by DAiS based on data provided by the NFZ.

101 Table 15: Share of hospitalised patients in particular hospitals by scope of treatment (2012)

to 1, to to 2 1, to

Healthcare provider/Scope of treatment –

hospitalisation ref. level II ref. level hospitalisation III ref. level hospitalisation

– –

hospitalisation

–

hospitalisation

hospitalisation hospitalisation

hospitalisation planned hospitalisation

–

– –

hospitalisation with combined treatment combined with hospitalisation

hospitalisation

– –

hospitalisation

–

hospitalisation

–

facial surgery surgery facial

cal oncology oncology cal

Brachytherapy Gastroenterology Otolaryngology therapy Isotope Urology Other

Chemotherapy Chemotherapy surgery Thoracic surgery Thoracic surgery General surgery General surgery Oncological Maxillo diseases Lung diseases Internal Endocrinology Neurosurgery Neurology Clini gynaecology and Obstetrics gynaecology and Obstetrics Teleradiotherapy Maria Skłodowska-Curie Institute of Oncology in Warsaw 6% 16% 4% 1% 27% 1% 2% 2% 17% 2% 6% 7% 3% 4%

Military Institute of Medicine in Warsaw 17% 5% 12% 1% 5% 1% 11% 4% 2% 2% 22% 2% 10% 5%

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 7% 5% 1% 18% 2% 48% 18%

Public Paediatric Central Clinical Hospital in Warsaw 5% 27% 22% 5% 13% 1% 4% 1% 9% 9% 2%

Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 11% 14% 17% 4% 3% 3% 1% 6% 1% 3% 4% 24% 9%

National Institute of Tuberculosis and Lung Diseases in Warsaw 8% 45% 27% 20%

Magodent Non-Public Healthcare Centre in Warsaw 24% 15% 33% 24% 5%

Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre 10% 11% 4% 16% 6% 3% 6% 8% 37%

Mazovian Specialist Hospital in Radom 32% 15% 28% 6% 1% 2% 3% 9% 3% 2%

Regional Polyclinical Hospital in Płock 9% 27% 16% 7% 4% 6% 5% 24% 2%

Infant Jesus Clinical Hospital in Warsaw 8% 6% 2% 3% 77% 3%

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 20% 15% 7% 57% 2%

Specialist Hospital in Siedlce 23% 5% 3% 3% 34% 5% 2% 26%

Międzylesie Specialist Hospital in Warsaw 7% 18% 2% 5% 4% 63% 1%

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 9% 10% 14% 12% 5% 8% 5% 37% 1%

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in Warsaw 16% 4% 5% 5% 68% 3%

Polyclinic of Bródno Clinical Centre 7% 14% 13% 17% 14% 6% 15% 14%

Regional Specialist Hospital in Ciechanów 20% 13% 15% 14% 3% 6% 3% 25%

John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki 16% 25% 3% 4% 52% Source: compiled by DAiS based on data provided by the NFZ.

The next stage of the analysis consisted in verifying what scope of healthcare services is provided to patients in previously selected 19 hospitals. Table 1414contains data on the number of patients in individual facilities by the scope of services, while Table 15 – on the share of patients in the hospital by the scope of services.

In selected hospitals, most patients received treatment related to urology (6.3 thousand), surgical oncology (5.9 thousand) and chemotherapy – hospitalisation with combined treatment (5.7 thousand).

The admission mode of cancer patients to hospitals in Mazowieckie Voivodeship was analysed next. Figure 107 shows data according to which 3/4 of patients were admitted in scheduled mode based on a referral. Another group was admitted on an emergency basis, excluding the

14 The number of unique patients does not equal the sum of cases treated in individual scopes, as one patient could be treated within several scopes during one year.

102 patients transported to the facility by paramedics. Every fifth patient in the Voivodeship was admitted in this mode.

Figure 107: Percentage of patients admitted in individual modes in Mazowieckie Voivodeship (2012)

Scheduled mode – based on a referral Emergency mode – other cases Emergency mode – transportation of the patient to the facility by paramedics Scheduled mode – privilege of priority Transfer from another hospital No data

Source: compiled by DAiS based on data provided by the NFZ.

103 Table 16: Number of patients by hospital admission mode (2012)

Healthcare provider/Admission type

other cases other

transportation of the patient to the facility by paramedics by facility to the patient the of transportation

based on a referral a on based of priority privilege

– –

from another hospital from another

TOTAL

Scheduled mode mode Scheduled mode Emergency mode Emergency mode Scheduled Transfer available data No patients Unique Maria Skłodowska-Curie Institute of Oncology in Warsaw 10,981 63 11 2 459 11516 11324

Military Institute of Medicine in Warsaw 2527 687 39 3,253 2942

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 2,570 17 1 2,688 2,674

Public Paediatric Central Clinical Hospital in Warsaw 1580 597 130 31 2,338 2168

Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 1570 590 153 2 1 2,316 2147

National Institute of Tuberculosis and Lung Diseases in Warsaw 2030 143 3 2176 2101

Magodent Non-Public Healthcare Centre in Warsaw 1643 175 1 2 1821 1726

Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre in Warsaw 862 356 183 1401 1334

Mazovian Specialist Hospital in Radom 821 613 202 1636 1277

Regional Polyclinical Hospital in Płock 745 665 58 1 1469 1274

Infant Jesus Clinical Hospital in Warsaw 1153 135 1 1289 1244

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 1082 5 1 1088 1083

Specialist Hospital in Siedlce 832 262 80 5 1179 1021

Międzylesie Specialist Hospital in Warsaw 528 509 113 2 1152 1016

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 556 416 60 4 1036 887

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in 733 91 63 2 889 867 Warsaw

Polyclinic of Bródno Clinical Centre 463 405 61 929 849

Regional Specialist Hospital in Ciechanów 537 337 102 3 979 840

John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki 487 4G5 33 925 831 Source: compiled by DAiS based on data provided by the NFZ.

Analysing collectively 19 hospitals providing treatment to the largest number of patients in Mazowieckie Voivodeship, this distribution is quite similar (79% and 17% of scheduled admissions based on a referral and emergency admissions – other cases, respectively).

In all of the hospitals analysed, patients were admitted mostly in scheduled mode based on a referral. (Table 1615, Figure 108). Transfers from another hospital as well as admissions of scheduled patients with priority privilege occurred only marginally in a handful of hospitals. There is no available data for Maria Skłodowska-Curie Institute of Oncology only. Data as percentage is shown in Figure 10816.

15 The number of unique patients does not equal the sum of admissions of patients in individual modes, as one patient may have been admitted several times in different modes during one year. 16 For reasons of clarity, the figure does not include the lines that represented the least numerous groups, namely "Transfer from another hospital", "Scheduled mode – priority" and missing data. Hospitals were ranked by the share of patients admitted in scheduled mode.

104 Figure 108: Percentage of patients admitted in particular hospitals including their admission mode (2012)

Scheduled mode – based on a referral Emergency mode – other cases Emergency mode – transportation of the patient to the facility by paramedics

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew Międzylesie Specialist Hospital in Warsaw Mazovian Center for Treatment of Lung Diseases and Tuberculosis

Polyclinic of Bródno Clinical Centre Maria Skłodowska-Curie Institute of Oncology in Warsaw

Mazovian Specialist Hospital in Radom National Institute of Tuberculosis and Lung Diseases in Warsaw

Megadent Non-Public Healthcare Centre in Warsaw Regional Polyclinical Hospital in Płock

John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki Infant Jesus Clinical Hospital in Warsaw

Józef Psarski Mazovian Specialist Hospital in Professor Witold Orłowski Independent Public Ostrołęka Clinical Hospital of the Medical Centre for Postgraduate Education in Warsaw

Regional Specialist Hospital in Ciechanów Military Institute of Medicine in Warsaw

Jerzy Popiełuszko Bielański Hospital – Independent Specialist Hospital in Siedlce Public Healthcare Centre in Warsaw Public

Paediatric Central Clinical Hospital in Warsaw Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

Source: compiled by DAiS based on data provided by the NFZ.

Almost in all hospitals included, the share of cancer patients admitted based on a referral was over 50%. Emergency admissions were similar in terms of quantity in the following facilities: Józef Psarski Mazovian Specialist Hospital in Ostrołęka, John Paul II Independent Public Specialist Western Hospital, Regional Polyclinical Hospital in Płock, Mazovian Specialist Hospital in Radom, Polyclinic of Bródno Clinical Centre and Międzylesie Specialist Hospital in Warsaw.

The next stage of the analysis consisted in checking what cancer types are treated in previously selected 19 hospitals. Table 1717 contains data on the number of patients in individual facilities by cancer type, while Table 1818 shows the share of these patients relative to all cancer patients in the hospital. In the hospitals selected, there were most patients treated for lung cancer (6.4 thousand) and for cancers not classified to any of the analysed groups (other, 5.3 thousand).

The number of unique patients does not equal the total of cancer cases, as one patient could be treated for several cancers during one year. 18Values below 5% are not shown for reasons of clarity.

105 Table 17: Number of patients in particular hospitals by cancer site (2012)

Healthcare provider/Cancer type

Central nervous system nervous Central

Melanoma tract gastrointestinal Lower Gynaecological neck and Head tract gastrointestinal Upper Testis Kidney Bladder Breast Lung Prostate Thyroid Other TOTAL patients Unique Maria Skłodowska-Curie Institute of Oncology in Warsaw 308 398 849 1590 848 625 136 146 234 2195 1233 333 1156 2,201 12,252 11324

Military Institute of Medicine in Warsaw 102 11 400 247 132 382 31 241 251 217 286 83 393 455 3,231 2,942

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 23 32 272 243 111 89 25 107 306 514 169 286 578 15 2,770 2,674

Public Paediatric Central Clinical Hospital in Warsaw 145 5 279 4 195 710 33 5 29 231 5 29 618 2,288 2168

Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 106 39 269 82 35 377 63 181 253 142 145 137 117 370 2,316 2147

National Institute of Tuberculosis and Lung Diseases in Warsaw 6 2 11 8 7 84 1 5 8 13 1733 12 5 258 2153 2101

Magodent Non-Public Healthcare Centre in Warsaw 2 46 382 137 17 172 28 55 81 535 119 56 41 266 1937 1726

Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre in Warsaw 61 1 189 113 74 155 17 66 384 15 88 54 12 134 1363 1334

Mazovian Specialist Hospital in Radom 70 9 200 90 69 135 2 8 15 123 450 9 6 190 1376 1277

Regional Polyclinical Hospital in Płock 47 12 214 74 79 85 6 45 218 126 239 84 2 88 1319 1274

Infant Jesus Clinical Hospital in Warsaw 2 1 44 46 58 65 19 164 626 5 8 182 61 1281 1244

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 9 1 9 4 5 7 10 7 7 996 9 3 38 1105 1083

Specialist Hospital in Siedlce 40 6 107 76 72 76 8 57 220 91 122 80 3 150 1108 1021

Międzylesie Specialist Hospital in Warsaw 36 2 59 4 44 57 13 87 285 2 49 285 4 121 1048 1016

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 22 12 73 42 68 63 3 74 245 74 120 43 3 91 933 887

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 23 1 89 44 6 41 17 41 491 10 18 42 11 38 872 867 Education in Warsaw

Polyclinic of Bródno Clinical Centre 161 1 77 144 134 176 2 1 13 67 1 1 87 865 849

Regional Specialist Hospital in Ciechanów 19 1 94 42 58 47 10 25 121 45 233 97 2 78 872 840

John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki 49 3 88 9 5 76 11 62 287 16 72 111 1 71 861 831 Source: compiled by DAiS based on data provided by the NFZ.

Table 18: Share of patients in particular hospitals by cancer site (2012)

Healthcare provider/Cancer type

Kidney

Central nervous system nervous Central Melanoma tract gastrointestinal Lower Gynaecological neck and Head tract gastrointestinal Upper Testis Bladder Breast Lung Prostate Thyroid Other Maria Skłodowska-Curie Institute of Oncology in Warsaw 7% 13% 7% 5% 18% 10% 9% 18%

Military Institute of Medicine in Warsaw 12% 8% 12% 8% 8% 7% 9% 12% 14%

"Zdrowie" Medical Centre/Oncology Hospital in Wieliszew 10% 9% 11% 19% 6% 10% 21%

Public Paediatric Central Clinical Hospital in Warsaw 6% 12% 9% 31% 10% 27%

Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw 12% 16% 8% 11% 6% 6% 6% 5% 16%

National Institute of Tuberculosis and Lung Diseases in Warsaw 81% 12%

Magodent Non-Public Healthcare Centre in Warsaw 20% 7% 9% 28% 6% 14%

Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre in Warsaw 14% 8% 5% 11% 28% 7% 10%

Mazovian Specialist Hospital in Radom 5% 15% 7% 10% 9% 33% 14%

Regional Polyclinical Hospital in Płock 16% 6% 6% 6% 17% 10% 18% 6% 7%

Infant Jesus Clinical Hospital in Warsaw 5% 13% 49% 14%

Mazovian Center for Treatment of Lung Diseases and Tuberculosis 90%

Specialist Hospital in Siedlce 10% 7% 7% 7% 5% 20% 8% 11% 7% 14%

Międzylesie Specialist Hospital in Warsaw 6% 5% 8% 27% 27% 12%

Józef Psarski Mazovian Specialist Hospital in Ostrołęka 8% 7% 7% 8% 26% 8% 13% 10%

106 Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in 10% 56% Warsaw

Polyclinic of Bródno Clinical Centre 19% 9% 17% 16% 20% 8% 10%

Regional Specialist Hospital in Ciechanów 11% 7% 5% 14% 5% 27% 11% 9%

John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki 6% 10% 9% 7% 33% 8% 13% 8% Source: compiled by DAiS based on data provided by the NFZ.

In none of the analysed hospitals patients with testicular cancer or melanoma represented more than 5% of cancer patients. Accordingly, it can be concluded that some hospitals have specialised in the treatment of certain cancer groups. In the Mazovian Center for Treatment of Lung Diseases and Tuberculosis, 90% of patients had lung cancer. Similarly, at the National Institute of Tuberculosis and Lung Diseases, lung cancer patients represented 81%.

Service providers analysis in terms of selected cancer groups

Malignant neoplasm of trachea, bronchus and lung (C33, C34)

Cancer of the trachea, bronchus and lung (hereinafter: lung) in 2012 represented the largest number of cancers treated in Mazowieckie Voivodeship. The patients were hospitalised mainly in the National Institute of Tuberculosis and Lung Diseases in Warsaw (1733), Maria Skłodowska-Curie Institute of Oncology in Warsaw (1233) and in the Mazovian Center for Treatment of Lung Diseases and Tuberculosis in Otwock (996). Figure 109 shows the share of lung cancer patients receiving treatment in particular counties in Mazowieckie Voivodeship19.

Figure 109: Share of lung cancer patients by the place of treatment (2010-2012)

Share of lung cancer in the voievodship

Source: compiled by DAiS based on data provided by the NFZ.

107 Note that the map shows all hospitals treating lung cancer patients rather than the largest 19 providers only. As it can be seen, over half of the patients were treated in Warsaw. Note the county of Otwock and Radom provided treatment to over 5% of patients with this diagnosis of all patients treated in Mazowieckie Voivodeship.

The number of lung cancer patients in the years 2010-2012 in previously selected 19 hospitals with the largest number of cancer patients is shown in Figure 110. Note that no hospital except for those presented in the figure provided treatment to more than 5% of all lung cancer patients in Mazowieckie Voivodeship. In the years 2010-2012, there were most lung cancer patients treated in the Nationtal Institute of Tuberculosis and Lung Diseases in Warsaw, Maria Skłodowska-Curie Institute of Oncology in Warsaw and in the Mazovian Centre for Treatment of Lung Diseases and Tuberculosis in Otwock.

Figure 110: Number of lung cancer patients by hospital (2010-2012)

item Name of the treatment provider

1 National Institute of Tuberculosis and Lung Diseases in Warsaw

2 Maria Skłodowska-Curie Institute of Oncology in Warsaw

3 Mazovian Center for Treatment of Lung Diseases and Tuberculosis

4 Mazovian Specialist Hospital in Radom

5 Military Institute of Medicine in Warsaw

6 Regional Specialist Hospital in Ciechanów

7 Regional Polyclinical Hospital in Płock

8 Public Paediatric Central Clinical Hospital in Warsaw

9 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

10 Józef Psarski Mazovian Specialist Hospital in Ostrołęka

11 Magodent Non-Public Healthcare Centre in Warsaw

12 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew

13 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre

14 Specialist Hospital in Siedlce

108 15 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki

16 Międzylesie Specialist Hospital in Warsaw

17 Polyclinic of Bródno Clinical Centre

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 18 Education in Warsaw

19 Infant Jesus Clinical Hospital in Warsaw Source: compiled by DAiS based on data provided by the NFZ.

Figure 111 illustrates the structure of 'old' patients, i.e. those who continue cancer treatment, and 'new' patients, i.e. those who have recently been diagnosed with cancer, by individual hospitals. The order of hospitals is as in Figure 110. "New" patients, i.e. those with newly diagnosed lung cancer, prevailed in all hospitals. Of the three hospitals providing treatment to the largest number of lung cancer patients, the highest percentage of newly diagnosed patients was reported at the National Institute of Tuberculosis and Lung Diseases (78%).

Figure 111: Structure of "old" and "new" patients by hospital (2010-2012)

Old patients New patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 112 presents the share of patients admitted in particular cancer stages in the group of newly admitted patients. The order of hospitals is as in Figure 110. Lung cancer patients are diagnosed relatively late. Stage III or IV patients prevailed in all of the analysed hospitals.

109 Figure 112: Share of patients in particular hospitals by cancer stage (2010-2012)

3-year incidence per 10,000 people

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Malignant neoplasm of breast (C50, D05)

Breast cancers are one of the most common ones in Mazowieckie Voivodeship. In 2012, patients with this cancer received treatment primarily in Maria Skłodowska-Curie Institute of Oncology (2,195). Figure 113 shows the share of breast cancer patients receiving treatment in particular counties in Mazowieckie Voivodeship.

Figure 113: Share of breast cancer patients by the place of treatment (2010-2012)

Cancer share in the voivoideship

Source: compiled by DAiS based on data provided by the NFZ.

Note that the map shows all hospitals treating breast cancer patients rather than the largest 19 providers only. 3 out of 4 patients received treatment in Warsaw. Moreover, over 6% of patients with this cancer from Mazowieckie Voivodeship received treatment in the county of Legionowo.

110 The number of breast cancer patients in previously selected 19 hospitals is shown in Figure 114. Note that no hospital except for those presented in the figure provided treatment to more than 5% of all breast cancer patients in Mazowieckie Voivodeship. In 2010-2012, most breast cancer patients received treatment in Maria Skłodowska-Curie Institute of Oncology.

Figure 114: Number of breast cancer patients by hospital (2010-2012)

item Name of the treatment provider

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw

2 Magodent Non-Public Healthcare Centre in Warsaw

3 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew

4 Military Institute of Medicine in Warsaw

5 Mazovian Specialist Hospital in Radom

6 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

7 Regional Polyclinical Hospital in Płock

8 Józef Psarski Mazovian Specialist Hospital in Ostrołęka

9 Regional Specialist Hospital in Ciechanów

10 Specialist Hospital in Siedlce

11 Public Paediatric Central Clinical Hospital in Warsaw

12 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki

13 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre in Warsaw

14 National Institute of Tuberculosis and Lung Diseases in Warsaw

15 Polyclinic of Bródno Clinical Centre

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 16 Education in Warsaw

17 Mazovian Center for Treatment of Lung Diseases and Tuberculosis

18 Infant Jesus Clinical Hospital in Warsaw

19 Międzylesie Specialist Hospital in Warsaw Source: compiled by DAiS based on data provided by the NFZ.

111 Figure 115 illustrates the structure of 'old' patients, i.e. those who continue cancer treatment, and 'new' patients, i.e. those who have recently been diagnosed with cancer, by individual hospitals. The order of hospitals is as in Figure 114. In the hospital providing treatment to the largest number of patients with this diagnosis, patients who continued treatment of the previously diagnosed cancer represented 40%.

Figure 115: Structure of "old" and "new" patients by hospital (2010-2012)

3-year incidence per 10,000 people

Old patients New patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 116 presents the share of patients admitted in particular cancer stages in the group of newly admitted patients. The order of hospitals is as in Figure 114. Patients are usually diagnosed at cancer stage II or III.

112 Figure 116: Share of patients in particular hospitals by cancer stage (2010-2012)

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

113 Malignant neoplasm of lower gastrointestinal tract (C18—C21)

Treatment for lower gastrointestinal tract cancer in 2012 was provided mainly in Maria Skłodowska-Curie Institute of Oncology (849). Figure 117 shows the share of lower gastrointestinal tract cancer patients receiving treatment in Mazovian counties19.

Figure 117: Share of lower gastrointestinal tract cancer patients by the place of treatment (2010-2012)

Cancer share in the voivoideship

Source: compiled by DAiS based on data provided by the NFZ.

The map shows all hospitals treating lower gastrointestinal tract cancer patients rather than the largest 19 Mazovian providers only. Most lower gastrointestinal tract cancer patients received treatment in Warsaw (61%).

The number of lower gastrointestinal tract cancer patients in previously selected 19 hospitals with the largest number of cancer patients is shown in Figure 118. No hospital except for those presented in the figure provided treatment to more than 5% of all lower gastrointestinal tract cancer patients in Mazowieckie Voivodeship. Most lower gastrointestinal tract cancer patients in the years 2010-2012 received treatment at Maria Skłodowska-Curie Institute of Oncology.

19 This means that it represents the share of patients from the voivodeship treated in the county. The map is based on data from 2010-2012

114 Figure 118: Number of lower gastrointestinal tract cancer patients by hospital (2010- 2012)

No. Name of the treatment provider

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw

2 Military Institute of Medicine in Warsaw

3 Public Paediatric Central Clinical Hospital in Warsaw

4 Magodent Non-Public Healthcare Centre in Warsaw

5 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

6 Regional Polyclinical Hospital in Płock

7 Mazovian Specialist Hospital in Radom

8 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre

9 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 10 Education in Warsaw

11 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki

12 Regional Specialist Hospital in Ciechanów

13 Specialist Hospital in Siedlce

14 Józef Psarski Mazovian Specialist Hospital in Ostrołęka

15 Międzylesie Specialist Hospital in Warsaw

16 Polyclinic of Bródno Clinical Centre

17 Infant Jesus Clinical Hospital in Warsaw

18 National Institute of Tuberculosis and Lung Diseases in Warsaw

19 Mazovian Center for Treatment of Lung Diseases and Tuberculosis Source: compiled by DAiS based on data provided by the NFZ.

Figure 119 illustrates the structure of 'old' patients, i.e. those who continue cancer treatment, and 'new' patients, i.e. those who have recently been diagnosed with cancer, by individual hospitals. The order of hospitals is as in Figure 118. In the hospital providing treatment to the

115 largest number of lower gastrointestinal tract cancer patients, patients who continued treatment of the previously diagnosed cancer represented 40%.

Figure 119: Structure of "old" and "new" patients by hospital (2010-2012)

Oldpatients New patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 120 presents the share of patients admitted in particular cancer stages in the group of newly admitted patients. The order of hospitals is as in Figure 118. Patients with this cancer were rarely diagnosed at the earliest cancer stage. They were most often diagnosed at cancer stage II or III.

Figure 120: Share of patients in particular hospitals by cancer stage (2010-2012)

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

116 Malignant neoplasm of prostate (C61)

In 2012, patients with prostate cancer received treatment primarily in the Centre

Figure 121 shows the share of prostate cancer patients receiving treatment in Mazovian counties20.

Figure 121: Share of prostate cancer patients by the place of treatment (2010-2012)

Cancer share in the voivoideship

Source: compiled by DAiS based on data provided by the NFZ.

The map shows all hospitals treating prostate cancer patients rather than the largest 19 providers only. 62% of patients received treatment in Warsaw. Note that county of Legionowo and Siedlce represented a share of over 5%.

The number of prostate cancer patients in previously selected 19 hospitals with the largest number of cancer patients is shown in Figure 122. Note that no hospital except for those presented in the figure provided treatment to more than 5% of all prostate cancer patients in Mazowieckie Voivodeship. Most prostate cancer patients in the years 2010-2012 received treatment at Maria Skłodowska-Curie Institute of Oncology and "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew.

20 This means that the map represents the share of patients from the voivodeship treated in the county. The map is based on data from 2010-2012.

117 Figure 122: Number of prostate cancer patients by hospital (2010-2012)

item Name of the treatment provider

1 Maria Skłodowska-Curie Institute of Oncology in Warsaw

2 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew

3 Międzylesie Specialist Hospital in Warsaw

4 Infant Jesus Clinical Hospital in Warsaw

5 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

6 Regional Specialist Hospital in Ciechanów

7 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre

8 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki

9 Military Institute of Medicine in Warsaw

10 Specialist Hospital in Siedlce

11 Regional Polyclinical Hospital in Płock

12 Magodent Non-Public Healthcare Centre in Warsaw

13 Józef Psarski Mazovian Specialist Hospital in Ostrołęka

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 14 Education in Warsaw

15 Mazovian Specialist Hospital in Radom

16 Mazovian Center for Treatment of Lung Diseases and Tuberculosis

17 Public Paediatric Central Clinical Hospital in Warsaw

18 National Institute of Tuberculosis and Lung Diseases in Warsaw

19 Polyclinic of Bródno Clinical Centre Source: compiled by DAiS based on data provided by the NFZ.

Figure 123 illustrates the structure of 'old' patients, i.e. those who continue cancer treatment, and 'new' patients, i.e. those who have recently been diagnosed with cancer, by individual hospitals. The order of hospitals is as in Figure 122. There were more patients with a newly

118 diagnosed cancer in all hospital except for Mazovian Specialist Hospital in Radom and Independent Public Central Clinical Hospital.

Figure 123: Structure of "old" and "new" patients by hospital (2010-2012)

Old patients New patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 124 presents the share of patients admitted in particular cancer stages in the group of newly admitted patients. The order of hospitals is as in Figure 122. In the first hospital, most patients were diagnosed at the second stage of cancer, while in the third, in terms of the number of patients with this cancer, almost half of the 'new' patients were diagnosed at stage I.

Figure 124: Share of patients in particular hospitals by cancer stage (2010-2012)

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

119 Malignant neoplasm of bladder (C67)

Bladder cancer comes next in the analysis.

In 2012, it was treated mainly in the Infant Jesus Clinical Hospital in Warsaw (626) and in the Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in Warsaw (491). Figure 125 shows the share of bladder cancer patients receiving treatment in particular counties in Mazowieckie Voivodeship21.

Figure 125: Share of bladder cancer patients by the place of treatment (2010-2012)

Cancer share in the voivoideship

Source: compiled by DAiS based on data provided by the NFZ.

The map shows all hospitals treating bladder cancer patients rather than the largest 19 providers only. As it can be seen, over 60% of the patients were treated in Warsaw. In the county of Grodzisk Mazowiecki and Siedlce more than 5% of patients receiving treatment in Mazowieckie Voivodeship were treated.

The number of bladder cancer patients in previously selected 19 hospitals with the largest number of cancer patients is shown in Figure 126. Note that no hospital except for those presented in the figure provided treatment to more than 5% of all bladder cancer patients in Mazowieckie Voivodeship. In the years 2010-2012, most bladder cancer patients were treated mainly in the Infant Jesus Clinical Hospital in Warsaw, Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre, and in the Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate Education in Warsaw.

21 This means that it represents the share of patients from the voivodeship treated in the county. The map is based on data from 2010-2012.

120 Figure 126: Number of bladder cancer patients by hospital (2010-2012)

item Name of the treatment provider

1 Infant Jesus Clinical Hospital in Warsaw

2 Jerzy Popiełuszko Bielański Hospital – Independent Public Healthcare Centre

Professor Witold Orłowski Independent Public Clinical Hospital of the Medical Centre for Postgraduate 3 Education in Warsaw

4 Międzylesie Specialist Hospital in Warsaw

5 John Paul II Independent Public Specialist Western Hospital in Grodzisk Mazowiecki

6 Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw

7 Military Institute of Medicine in Warsaw

8 Maria Skłodowska-Curie Institute of Oncology in Warsaw

9 Józef Psarski Mazovian Specialist Hospital in Ostrołęka

10 "Zdrowie" Medical Centre/Oncology Hospital in Wieliszew

11 Regional Polyclinical Hospital in Płock

12 Specialist Hospital in Siedlce

13 Regional Specialist Hospital in Ciechanów

14 Magodent Non-Public Healthcare Centre in Warsaw

15 Mazovian Specialist Hospital in Radom

16 Mazovian Center for Treatment of Lung Diseases and Tuberculosis

17 National Institute of Tuberculosis and Lung Diseases in Warsaw

18 Public Paediatric Central Clinical Hospital in Warsaw

19 Polyclinic of Bródno Clinical Centre Source: compiled by DAiS based on data provided by the NFZ.

Figure 127 illustrates the structure of 'old' patients, i.e. those who continue cancer treatment, and 'new' patients, i.e. those who have recently been diagnosed with cancer, by individual hospitals. The order of hospitals is as in Figure 126. In almost all hospitals, patients were more likely to continue treatment of previously diagnosed cancer.

121 Figure 127: Structure of "old" and "new" patients by hospital (2010-2012)

Old patients New patients

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 128 presents the share of patients admitted in particular cancer stages. The order of hospitals is as in Figure 126. Patients admitted at stage IV prevail in most of the analysed hospitals. Patients are diagnosed the most rarely at stage I.

Figure 128: Share of patients in particular hospitals by cancer stage (2010-2012)

Stage I Stage II Stage III Stage IV Source: compiled by DAiS based on data provided by the KRN and the NFZ.

2.1.4 Surgical and Conservative Treatment Analysis

In order to compare the activity of facilities providing oncology-related services in Mazowieckie Voivodeship, a comparative analysis was done in terms of the number and type of reported oncology-related hospitalisations and the number of radical surgeries for major cancer types.

In the first stage, the analysis covered the number of hospitalisations performed for oncology- related reasons. All oncology-related hospitalisations funded under the DRGs were taken into account, i.e. excluding those for chemotherapy, radiotherapy and those associated with the 1b index. Reported healthcare services have been divided into two groups: (1) conservative

122 treatment DRGs and 2) surgical treatment DRGs. Surgical treatment DRGs are marked with “*” in 1a index.

Figures 129 to 130 present the number of healthcare services in selected DRG groups reported by each provider. For example, service provider A on Figure 129 reported approx. 1.5 thousand DRGs classified as conservative treatment and approx. 5,000 surgical treatment services. The ratio of conservative DRGs to surgical ones for the entire voivodeship is marked in bold. Health care providers below this line for each reported conservative DRGs report more surgical DRGs than the average in the voivodeship. The other three lines divide the figure into four fields. The middle straight line divides the figure into two parts: service providers above the line provide more conservative than surgical healthcare services. The field below the line should be interpreted in a corresponding manner. The uppermost straight line denotes the service providers who perform at least two conservative treatment services per each surgical treatment service. Health care providers performing treatment and conservative services in a ratio of 2:1 or more are below the lowermost straight line (the area where point A is located).

In 2012, healthcare providers reported over 24.1 thousand surgical treatment DRGs and over 17 thousand conservative treatment DRGs in Mazowieckie Voivodeship. Based on the analysis of Figure 129, it was found that in 2012, the Voivodeship had most providers reporting up to 600 oncology-related hospitalisations (as defined according to the criterion described above). Five healthcare providers reported 1500 or more oncology-related admissions to the hospital (white box). Only one of them reported over twice as many surgical treatment DRGs than conservative treatment DRGs. Such fact was also disclosed by four other healthcare providers who reported from 600 to 1500 DRGs. The cluster of these providers is marked in the figure by number I.

Among sixteen service providers who reported between 600 and 1,500 DRGs, seven had the rate of hospitalisation with conservative treatment DRGs to hospitalisation with surgical treatment DRGs between approx. 1.5:1 and approx. 2:1. This means that per every one hundred oncology-related services these providers perform services between approx. 40 and approx. 67 services classified as conservative.

Points marked with number I correspond to four service providers reporting mainly surgical treatment DRGs. The rate of hospitalisation with conservative treatment DRGs to hospitalisation with surgical treatment DRGs ranges from approx. 1:2.5 to approx. 1:26. This means that per every one hundred hospitalisation these providers perform services between approx. 71 and approx. 96 surgical services. The remaining points in the graph correspond to small service providers who reported less than 600 DRGs or the rate of reported conservative DRGs to surgical ones is lower than 2:1. This means that per every one surgical DRG these service providers report less than two conservative DRGs.

123 Figure 129: Ratio of reported conservative treatment DRGs to surgical treatment DRGs

(real-world data) (2012)

Conservative DRGs treatment

Ratio of conservative treatment DRGs Number of accounted DRGs Conservative to surgical treatment DRGs treatment DRGs 2:1,1:2 1:1 Voivodeship rate

Source: compiled by DAiS based on data provided by the NFZ.

The findings are based on raw data, without taking into account the structure of patients by cancer type and stage, i.e. the two variables that are the key determinant of the treatment mode of a patient. Standardization results for these two variables are shown in Figure 130.

Figure 130: Ratio of reported conservative DRGs to surgical ones (data standardized for

cancer type and stage) (2012)

Conservative DRGs treatment

Ratio of conservative treatment DRGs Number of accounted DRGs Conservative to surgical treatment DRGs treatment DRGs 2:1,1:2 1:1 Voivodeship rate

Based on the analysis of standardizeddata, it was found that the differences in service providers are smaller compared to raw data after discarding differences in the structure of patients. The majority of service providers had an increased share of hospitalisation with conservative DRGs. Thus, assuming that the patient breakdown by cancer type and stage is

124 consistent with the regional breakdown, only two out of five largest healthcare providers would report surgical and conservative treatment in a ratio higher than the regional ratio.

Figure 131 shows corresponding data in geographical terms. Large facilities (i.e. those performing over 1 thousand surgical treatment DRGs) with positive ratio of surgical treatment DRGs to conservative treatment DRGs22 (green and blue) are located in Warsaw. The majority of the remaining facilities reported a relatively low number of surgical treatment DRGs or presented a negative ratio of the number of conservative DRGs to treatment DRGs. Moreover, many of them are relatively small (less than 250 DRGs) and are located close to the other facilities.

22After discarding the factor of the cancer type and stage.

125 Figure 131: Ratio of reported conservative DRGs to surgical ones (data standardized for cancer type and stage) (2012)

Scale (number of surgical DRGs)

Distribution in municipalities with > 1 facility

Rate of surgical DRGs to conservative ones (colour)

>2:1 (2:1, voivodeship rate) (voivodeship rate, 2:1) <1:2 <1 facility in the municipality

Source: compiled by DAiS based on data provided by the NFZ.

The services reported under surgical DRGs were analysed next. DRGs were selected from this group under which the reported procedure was defined as a radical procedure (procedures were indicated separately for each cancer type based on the International Classification of Medical Procedures ICD-9) and DRGs without these procedures. Reported DRGs with a radical procedure in 2012 in Mazowieckie Voivodeship amounted to approx. 12.2 thousand. The rate of reported DRGs according to the division described is presented in Figure 132.

Figure 132: Ratio of reported surgical DRGs with radical surgery to surgical DRGs

without radical surgery (real data) (2012)

Surgical DRG, notreatment radical

Surgical DRG, radical treatment Number of reported DRGs Rate of DRGs with radical procedures involving radical treatment to DRGs without radical procedures

<=200 2:1,1:2 (200;600> 1:1 >=600 Voivodeship rate

Source: compiled by DAiS based on data provided by the NFZ.

Based on Figure 132 it was found that 85% of healthcare providers reported less than 200 radical surgeries in 2012. This means that, assuming a 200-day working year, these providers reported on average less than 1 radical procedure per day (taking into account all groups of analysed cancers). This leads us to a conclusion that radical surgical procedures are largely

126 dispersed across Mazowieckie Voivodeship. Moreover, most service providers were situated in the area between the extreme straight lines in the graph (grey colour). This means that they reported the services in a rate of 1:2 to 2:1. The four largest providers reporting mainly hospitalisation with a radical procedure were identified, wherein one (A) reported almost 800 such hospitalisations.

After discarding the factor of diagnosis and stage, most providers were found to be approaching the empirical voivodeship rate. Assuming a diagnosis and stage structure typical for the whole voivodeship among service providers, the differences between the service provider marked with the letter A in Figure 132 and the other service providers in the voivodeship would be reduced.

Figure 133: Ratio of reported surgical DRGs with radical surgery to surgical DRGs

without radical surgery (data standardized for cancer type and stage) (2012)

Surgical DRG, notreatment radical

Surgical DRG, radical treatment Number of reported DRGs Rate of DRGs with radical procedures involving radical treatment to DRGs without radical procedures

<=200 2:1,1:2 (200;600> 1:1 >=600 Voivodeship rate

Source: compiled by DAiS based on data provided by the NFZ.

The analysis of service providers in terms of surgical DRGs next involved a detailed analysis of the number of radical procedures reported depending on the cancer (the horizontal axis above the analysed graphs). The correlation between the number of surgical procedures performed annually in a hospital and their efficiency (as measured using mortality rates, average hospitalisation time etc.) was discussed in multiple medical papers and statistics within the last 20 years.23A general conclusion that can be drawn therefrom is the positive correlation between the number of patients that have undergone a specific surgical treatment

23 Relevant reviews are available e.g. in Annals of Oncology, European Journal of Surgical Oncology, New England Journal of Medicine.

127 in a particular facility and the quality of treatment. Facilities that annually provided on average more services of a given type had lower mortality rates24rfewer complications and shorter hospitalisation times. 2526Researchers also found a similar correlation between the number of procedures performed annually by one physician and the effectiveness of such procedures.27

The correlations described above refer to a large extent to cancer surgery. In 2003, Birkmeyer et al. demonstrated, using the Medicare programme database, that for all of the four types of cancer surgery (lung resection, pancreatectomy, esophagectomy and cystectomy), the mortality rate of patients substantially decreases with the number of surgeries performed per year. Differences in the mortality rate were significant, e.g. for esophagectomy with one surgery per year, the mortality within 30 days after surgery was 18.8%, while if the surgeon performed more than six such procedures, the mortality rate was 9.2%.

Hu et al. (2003), when examining the discussed correlations as regards prostatectomy, also on the basis of the Medicare dataset, for the sake of clarity, divided hospitals and physicians into two groups by the number of procedures per year. The threshold value for hospitals was 60 treatments per year, and for oncology surgeons – 40 treatments per year. The findings indicated that patients treated by physicians with less experience, i.e. performing less than 40 prostatectomies twice more often a year had complications, were hospitalised one day longer on average. On the other hand, hospitals performing less than 60 surgeries a year recorded almost 7 percentage points fewer cases of stenoses in the place of anastomosis in their patients, as well asthey hospitalised patients by 0.8 days less on average.

Researchers and institutions use the discussed correlations between the number of patients admitted and the effectiveness of the treatment process as the basis for preparing recommendations and criteria for both providers and surgeons. Examples of such recommendations include e.g.

• Querleu et al. (2013) ,where it is proposed for facilities to perform a minimum of 20 ovarian cancer resections28,

• Surgeons specializing in breast cancer surgeries should, according to the Association for Breast Surgery, perform at least 30 such procedures a year29,

24Begg, Colin B., et al. ’’Impact of hospital volume on operative mortality for major cancer surgery.”Jama 280.20 (1998): 1747- 1751. 25Hu, Jim C., et al. Role of surgeon volume in radical prostatectomy outcomes.”Journal of Clinical Oncology 21.3 (2003): 401-405. 26Birkmeyer, John D., et al. Surgeon volume and operative mortality in the United States.Ńew England Journal of Medicine 349.22 (2003): 2117-2127. 27 Birkmeyer, John D., et al. Surgeon volume and operative mortality in the United States.New England Journal of Medicine 349.22 (2003): 2117-2127. 28Querleu, D., et al. ’’Quality indicators in ovarian cancer surgery: Report from the French Society of Gynecologic Oncology (Societe Francaise d’Oncologie Gynecologique, SFOG). Annals of oncology (2013): mdt237 29Association of Breast Surgery at Baso 2009.Surgical guidelines for the management of breast cancer. European Journal of Surgical Oncology (EJSO)35 (2009): S1-S22

128 • Specialists performing lung resections should, according to Brunelli et al. (2009), perform at least 20-25 surgeries of this type a year.

Cancers of lower gastrointestinal tract, breast and prostate were considered next Three cut- off levels of 250, 150 and 60 radical surgery were looked upon. The first cut-off point assumes one radical surgery per day on average reported by a given provider. The level of the second one means that, assuming the number of surgeons of 3, each of them performs one radical treatment per week on average.30 In the third case, the assumed average number of procedures per surgeon was reduced to 20.

Figures 134-136 present the data corresponding to the cancers under consideration. Units reporting above and below 60 surgeries a year (the lowest considered level) are highlighted. Horizontal lines indicate the considered cut-off points (i.e. 250, 150 and 60 surgeries per year).

As regards lower gastrointestinal tract cancer, nine service providers were identified reporting over 60 procedures considered, including one to have reported over 250 procedures (Figure 134). Other service providers reported less than 60 surgeries considered (a total of 881). The concentration of these dispersed surgeries across Mazowieckie Voivodeship would allow for the operation of another:

• 3 service providers performing over 250 procedures each, or

• 6 service providers performing over 150 procedures on average each, or

• 15 service providers performing over 60 procedures on average each.

Figure 134: Number of reported radical surgical procedures for lower gastrointestinal tract cancer by hospital (2012)

Lower gastrointestinal tract cancer

Number of surgeries Over 60 Below 60 Source: compiled by DAiS based on data provided by the NFZ.

30 Basket requirements refer to a minimum of two surgeons, however, factoring in holidays and sick leaves, it was assumed that three surgeons are associated with a facility.

129 Figure 135 presents corresponding data for breast cancer. It was found that, as in the case of lower gastrointestinal cancer, service providers are largely dispersed in terms of the number of reported breast surgeries: only 7 out of 50 service providers (i.e. 14%) reported a number of radical surgeries above the minimum level considered. Of these, 250 or more surgeries of this type were reported by two service providers, and two who ranked next reported more than 150 such surgeries. Healthcare services reported by service providers who reported 60 or less surgeries accounted for almost one forth of all radical surgeries reported. The concentration 31of these dispersed surgeries (in total 439) across Mazowieckie Voivodeship would allow for the operation of e.g.:

• 3 service providers performing over 150 procedures, or

• 7 service providers performing over 60 procedures on average each.

Figure 135: Number of reported radical surgical procedures for breast cancer per treatment provider in Mazowieckie Voivodeship (2012)

Breast cancer

Number of surgeries Over 60 Below 60 Source: compiled by DAiS based on data provided by the NFZ.

In the case of prostate cancer, no facility was identified to report more than 150 radical procedures. Four healthcare service providers reported over 60 such procedures. In Mazowieckie Voivodeship, these procedures were distributed to a large degree between healthcare providers: 85% reported less than 60 radical procedures (237 in total). Concentration of these surgical procedures in Mazowieckie Voivodeship would allow for the operation of e.g. four service providers providing almost 60 radical procedures.

31 It should be noted that there are no reasons for a large degree of dispersion of service providers performing radical surgeries. Unlike in the case of radiotherapy and chemotherapy services, the patient usually undergoes surgery once, so that the concentration of services in fewer centres does not mean a real deterioration of access to the services (there is no need for the patient to repeatedly travel over long distance in order to use the service, as a radical surgery is usually performed once).

130 Figure 136: Number of reported radical surgical procedures for prostate cancer by hospital (2012)

Prostate cancer

Number of surgeries Over 60 Below 60 Source: compiled by DAiS based on data provided by the NFZ.

Figure 137: ALOS with regard to conservative treatment DRGs per hospital in days (2012)

ALOS (left axis) ALOS in the voivodeship (right axis)

Source: compiled by DAiS based on data provided by the NFZ.

The conservative treatment DRGs reported by healthcare providers were analysed in terms of the average length of stay (hereinafter referred to as ALOS). The respective data was presented in Figure 137. The axis shows ALOS of patients in the given healthcare provider as well as ALOS in the voivodeship. By analysing this graph, it was found that more than one in two patients, the value of the analysed variable was higher than in the voivodeship. Presented data does not take into consideration in-patients (reported with conservative treatment DRG); thus, it may bias the conclusions. In order to properly interpret the data, the number of such patients was presented in Figure 138 (yellow field, values shown on right axis). This approach, among other things, enabled the observation that the healthcare provider with the highest value of ALOS statistics hospitalised a small number of patients (close to 0). The ALOS in the case of four healthcare providers reporting at least 400 DRGs of 4-6 days. This means that the patients hospitalised by those healthcare providers have been undergoing conservative treatment within a DRG during 4-6 days on average. The ALOS for the biggest healthcare provider oscillated at the level of 8 days.

131 Figure 138: Average length of stay and the number of hospitalised patients for selected healthcare providers within reported conservative treatment DRGs (2012)

Number of patients (right axis) ALOS (left axis) ALOS in the voivodeship (right axis)

Source: compiled by DAiS based on data provided by the NFZ.

The differences in analysed statistics are mainly due to the diversified structure of hospitalised patients as regards conservative DRGs. Assuming that each provider had a patient structure corresponding to that of the voivodeship in term of the cancer type and stage, the differences would be less substantial, see Figure 139. ALOS for the majority of healthcare providers would be reduced, which was presented using the red part of bars. The greatest decrease (of up to 60%). in ALOS was observed in service providers hospitalising few patients. This means that the average length of stay at these providers is mainly due to the structure of cancer and the diagnosis stage among hospitalised patients. In eleven cases, the analysed variable increased.

Assuming a cancer type and stage structure corresponding to that of the voivodeship, in the group of the service providers reporting more than 200 hospitalisations under conservative DRGs, the average length of stay of the patient would not exceed seven and a half days.

Figure 139: Average length of stay (cancer breakdown standardised and voivodeship severity standardised) and the number of hospitalised patients (yellow area) for selected healthcare providers within reported conservative treatment DRGs (2012) Greater value

Number of surgeries Before standardisation After standardisation

Source: compiled by DAiS based on data provided by the NFZ.

132

2.1.5 Chemotherapy Services Analysis

In 2012, there were 28 Mazovian facilities providing chemotherapy treatment and were parties to contracts with the third-party public payer. Figure 140 shows the geographic distribution thereof. Their facilities were located in Warsaw (16), Otwock (2), Radom (2), Wieliszew (1), Grodzisk Mazowiecki (1), Mrozy (1), Siedlce (1), Płock (1), Ostrołęka (1) and Ciechanów (1).

Figure 140: Distribution of facilities providing chemotherapy NFZ services (2012)

Source: compiled by DAiS based on data provided by the NFZ.

Mazovian healthcare providers were compared in terms of chemotherapy services reported. Treatment services were identified in hospitalisation, one-day and outpatient modes. Figure 141 provides information on the structure of the chemotherapy services reported in individual facilities. They were ranked in decreasing order of the total number of chemotherapy services performed. The largest healthcare provider performed a total of 46% of all chemotherapy services in the voivodeship. More specifically, it performed 32,154 one-day chemotherapy services (76.5% of all chemotherapy services it reported), which accounted for 54.2% of all chemotherapy services provided in this mode in the voivodeship and 2,848 chemotherapy services in outpatient mode (6.8% of all chemotherapy services it reported), which accounted for 26.6% of all chemotherapy provided in this mode in the voivodeship. It also performed 7,038 chemotherapy services combined with hospitalisation (16.7% of all chemotherapy services it reported), which accounted for 33.1% of all chemotherapy provided in this mode in the voivodeship.

The second largest healthcare provider performed 10% of all chemotherapy services in the voivodeship. This number includes 6,550 chemotherapy services provided in one-day mode (71.9% of all chemotherapy services it reported, being 11% of all one-day chemotherapy

133 services provided in the voivodeship), 523 chemotherapy services provided in outpatient mode (5.7% of the chemotherapy services it reported, i.e. 4.9% of all outpatient chemotherapy services in the voivodeship) and 2,044 chemotherapy services combined with hospitalisation (22.4% of all chemotherapy services it reported, 9.6% of all chemotherapy combined with hospitalisation provided in the voivodeship).

The third largest healthcare provider performed 5.9% of all chemotherapy services in the voivodeship. This number includes 2,166 chemotherapy services provided in one-day mode (40.3% of all chemotherapy services it reported, being 3.7% of all one-day chemotherapy services provided in the voivodeship), 791 chemotherapy services provided in outpatient mode (14.7% of the chemotherapy services it reported, i.e. 7.4% of all outpatient chemotherapy services in the voivodeship) and 2,418 chemotherapy services combined with hospitalisation (45% of all chemotherapy services it reported, i.e. 11.4% of all chemotherapy involving hospitalisation provided in the voivodeship).

Figure 141: Structure of reported chemotherapy treatments by providers (2012)

Share of chemotherapy Combined with Day treatment Outpatient treatment hospitalisation

Source: compiled by DAiS based on data provided by the NFZ.

Another aspect of the comparison of the activity of service providers in Mazowieckie Voivodeship relates to the chemotherapy services reported. Treatment services were identified in hospitalisation, one-day and outpatient modes. Rate of the number of patients reported under one-day and outpatient services to hospitalisations is shown in Figure 142. The number of out-patients undergoing chemotherapy is almost twice as high as the number of in-patients undergoing chemotherapy within the region, which is significantly affected by service provider A, which provides chemotherapy services to the largest number of patients in Mazowieckie Voivodeship. It was found that there is a division into service providers that report

134 hospitalisation mode chemotherapy more often, and those that are more likely to report chemotherapy services provided in one-day and outpatient mode.

Figure 142: Rate of the number of patients reported under one-day and outpatient

services to hospitalisations (2012)

day andoutpatient dayservices

- One

Hospitalisations Rate of the number of patients reported under one-day and outpatient services to hospitalisations

2:1,1:2 1:1 Voivodeship rate Source: compiled by DAiS based on data provided by the NFZ.

The ratio of the number of person-days reported under the analysed types of services is shown in Figure 143. Thus, the vast majority of service providers reported more person-days of hospitalisation than under one-day and outpatient services. Therefore, despite the fact that service provider A reports more person-days of one-day or outpatient chemotherapy services, there was relatively more person-days in hospitalisation mode on average in the voivodeship.

135 Figure 143: Rate of the number of person-days reported under one-day and outpatient

services to hospitalisations (2012)

day andoutpatient dayservices

- One

Hospitalisations

Rate of the number of patients reported under one-day and outpatient services to hospitalisations 2:1,1:2 1:1 Voivodeship rate

Source: compiled by DAiS based on data provided by the NFZ.

The larger relative number of person-days in hospitalisation mode may be due to the diverse structure of hospitalised patients in relation to the cancer type and stage. The relation of the analysed variables after discarding the factor of this structure is shown in Figure 144. As the service provider marked with the letter A in Figure 143 primarily defined the voivodeship structure, in its case the standardisation process did not affect the ratio of the number of chemotherapy person-days in the hospitalisation mode to the other modes. From the point of view of the remaining part of the population of service providers, the discarding the factor of the structure of cancer type and stage has minimally changed their situation versus the empirical ratio for the entire voivodeship. For comparison, Figure 145 shows all service providers in Mazowieckie Voivodeship (except the largest one).

136 Figure 144: Rate of the number of person-days reported under one-day and outpatient services to hospitalisations – without the major provider (standardization for the

distribution of cancers) (2012)

day andoutpatient dayservices

- One

Hospitalisations Rate of the number of patients reported under one-day and outpatient services to hospitalisations

2:1,1:2 1:1 Voivodeship rate

Source: compiled by DAiS based on data provided by the NFZ.

Figure 145: Rate of the number of person-days reported under one-day and outpatient

services to hospitalisations (standardization for the distribution of cancers) (2012)

day andoutpatient dayservices

- One

Hospitalisations Rate of the number of patients reported under one-day and outpatient services to hospitalisations

2:1,1:2 1:1 Voivodeship rate Source: compiled by DAiS based on data provided by the NFZ.

One-day chemotherapy services were prevalent in Mazowieckie Voivodeship. Services combined with hospitalisation ranked second. Figure 146 illustrates the number of

137 chemotherapy treatment services performed for patients from Mazovian counties and the structure of performed chemotherapy treatment services for patients residing in these counties (the second data type is represented by pie charts for individual counties).

Most chemotherapy treatment services were provided to patients from Warsaw (33,371), Radom (3,667) and the county of Wołomin (2,751) Zwoleń (325) and Białobrzegi (408) counties perform the least chemotherapy treatments.

Figure 146: Number and structure of chemotherapy treatment services by the place of residence of the patient (2012)

Number of chemotherapy treatments Share of chemotherapy treatments provided to patients from the county provided to patients from the county

Outpatient treatment Day treatment Including hospitalisation

Source: compiled by DAiS based on data provided by the NFZ.

Another important piece of information included in Figure 146 is the structure of the modes of the provided services. 12% of chemotherapy treatment services provided to patients from the voivodeship was performed in outpatient mode. The highest percentage of chemotherapy treatment of this type was recorded for patients from the counties of Siedlce (52%) and Łosice (48%). 65.8% of chemotherapy services provided to the population of the voivodeship was performed in one-day mode. The highest percentage of chemotherapy treatment of this type was recorded for patients from Ostrołęka (82%) and the county of Grodzisk Mazowiecki (81%). Chemotherapy combined with hospitalisation is yet another important group of services. It accounted for 21% of chemotherapy services in the voivodeship. Szydłowiec (45%) and Białobrzegi (43%) counties had the highest share of chemotherapy involving this procedure. These counties had no oncology hospitals (Figure 98).

138 The number of respective services per 1,000 patients with diagnosed cancer from the county was used to illustrate the intensity of the chemotherapy services provided.32

The number of chemotherapy services per 1,000 patients diagnosed with cancer was calculated. This rate was also standardized for the structure of cancer groups and the structure of stages among all cancer patients from the voivodeship.

Figure 147: Number of chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients (2012) Number of chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

Figure 147 shows the number of outpatient chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients from counties. Counties with high values were grouped in the east and south of the voivodeship. The highest values of the rate were recorded in Siedlce (462) and Radom (423). The lowest number of chemotherapy treatment services performed in this mode per 1,000 patients was recorded in the county of Sierpc (22).

32 In 0.69% of all the entries to the National Health Fund database analysed for 2012, an incorrect TERYT code was provided, making it impossible to clearly identify the territorial administrative unit. In such cases, it was assumed that the place of residence of these patients is the same as their place of treatment.

139 Figure 148: Number of chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients (2012) standardized for cancer group and stage

Number of chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

Following standardization (Figure 148), there were no significant changes in the structure of counties having low and high values of the rate. Thus, the structure of cancer groups and stages was not the only factor affecting the number of chemotherapy treatment services in outpatient mode per 1,000 patients. The highest standardized number of chemotherapy treatment services in outpatient mode per 1,000 cancer patients was performed for inhabitants of Siedlce (438) and Radom (421).

140 Figure 149: Number of chemotherapy treatment services performed in one-day mode per 1,000 cancer patients (2012) Number of chemotherapy treatment services performed in one-day mode per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

Figure 149 shows the number of one-day chemotherapy treatment services performed in outpatient mode per 1,000 cancer patients from Mazovian counties. The highest values were reported in the eastern- and northernmost regions of the Voivodeship. Southern and eastern counties have low values of the rate. Ostrołęka (909), the counties of Ostrołęka (845) and Grodzisk Mazowiecki (936) had a particularly large number of one-day chemotherapy treatments per 1,000 patients. The lowest rates were recorded in the counties of Siedlce (144) and Zwoleń (202).

141 Figure 150: Number of chemotherapy treatment services performed in one-day mode per 1,000 cancer patients (2012) standardized for cancer group and stage

Number of chemotherapy treatment services performed in one-day mode per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

The standardized number of one-day chemotherapy treatments per 1,000 patients diagnosed with cancer from Mazovian counties is shown in Figure 150. As it can be seen, the counties with a high value of the rate are still concentrated in the western- and easternmost regions of the voivodeship. Thus, the structure of cancer groups and stages was not the only factor affecting the number of chemotherapy treatment services in one-day mode per 1,000 patients.

142 Figure 151: Number of chemotherapy treatment services involving hospitalisation per

1,000 cancer patients (2012) Number of chemotherapy treatment services involving hospitalisation per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

Figure 151 shows the number of chemotherapy treatment services involving hospitalisation performed in outpatient mode per 1,000 cancer patients from counties. As it can be seen, the counties with a high value of the rate are grouped mainly in the southern- and easternmost regions of the voivodeship. Most chemotherapy treatments involving hospitalisation was recorded in the counties of Białobrzegi (414) and Szydłowiec (389). The lowest values, in turn, were observed in Ostrołęka (100) and the county of Ostrołęka (192).

143 Figure 152: Number of chemotherapy treatment services involving hospitalisation per 1,000 cancer patients (2012) standardized for cancer group and stage

Number of chemotherapy treatment services involving hospitalisation per 1,000 cancer patients from the county

Source: compiled by DAiS based on data provided by the NFZ.

Figure 152 shows the standardized number of chemotherapy treatment services involving hospitalisation performed in outpatient mode per 1,000 cancer patients from Mazovian counties. As a result of standardisation, there were no substantial changes observed in the number of chemotherapy services involving hospitalisation per 1,000 cancer patients. Thus, the structure of cancer groups and stages was not the only factor affecting the number of chemotherapy treatment services in one-day mode per 1,000 patients.

2.1.6 Radiotherapy Services Analysis

In 2012, 34 facilities in Poland reported radiotherapy services. They reported services provided to almost 65,000 patients. Teletherapy services were provided by 27 hospitals, which admitted a total of over 56.5 thousand unique patients. For brachytherapy, 28 facilities reported a total of almost 8.8 thousand patients. For isotope therapy, 10 facilities reported services provided to approx. 4.5 thousand unique patients. Table 19 presents the hospitals that provided radiotherapy services in 2012, including the number of patients admitted in particular scopes.

144 Table 19: Patients admitted for brachytherapy, teletherapy and isotope therapy (2012)

voivodeship city treatment provider

teletherapy brachytherapy therapy Isotope radiotherapy

Wałbrzych Alfred Sokołowski Specialist Hospital 1051 231 - 1,196 Dolnośląskie Wrocław Dolnośląskie Oncology Centre 3174 419 - 3,246

Kujawsko-Pomorskie Bydgoszcz Professor Franciszek Łukaszczyk Oncology Centre 3,594 745 - 4305

Lubelskie Lublin St. John of Dukla Lublin Regional Oncology Centre Independent Public Healthcare Centre 2,555 395 - 2,750

Lubuskie Zielona Góra Provincial Hospital Independent Public Healthcare Centre 965 115 - 1005

Central Teaching Hospital Institute of Dentistry of the Medical University Independent Public Healthcare - - 13 13 Łódź Centre Łódzkie Nicolaus Copernicus Regional Specialist Hospital 2 7S4 430 - 2,932

Zgierz Maria Skłodowska-Curie Provincial Specialist Hospital - - 495 495

Oncology Centre Hospital - Kraków Division Institute 1868 391 22 2,102

Kraków Children's Hospital 751 - - 751 Małopolskie University Hospital Healthcare - 397 205 605

Tarnów Saint Luke's Provincial Hospital Independent Public Healthcare Centre 1019 90 - 1043

Central Clinical Hospital of the Ministry of the Interior and Administration - - 99 99

Warsaw Maria Skłodowska-Curie Institute of Oncology 6755 534 1,562 5546 Mazowieckie Military Institute of Medicine - - 165 165

Wieliszew Mazovian Oncology Hospital 1540 220 - 1635

Opolskie Opole Professor Koszarowski Oncology Centre in Opole Independent Public Healthcare Centre S7S 144 - 950

Brzozów Bronisław Markiewicz Subcarpathian Oncology Centre 1091 32.1 - 1292 Podkarpackie Rzeszów Fryderyk Chopin Regional Specialist Hospital 1273 91 - 1315

Podlaskie Białystok Maria Skłodowska-Curie Oncology Centre in Białystok 1439 239 - 1,570

Gdańsk University Clinical Centre 1501 207 - 1535 Pomorskie Gdynia Polish Red Cross Maritime Hospital 1205 174 - 1255

Bielsko-Biała John Paul II Oncology Centre of Beskidy 1243 65 - 1251

Częstochowa Blessed Virgin Mary’s Regional Specialist Hospital 1057 57 - 1103 Śląskie Gliwice Maria Skłodowska-Curie Oncology Centre-Institute 5550 750 1162 7,414

Katowice Stanisław Leszczyński Hospital 2175 143 - 2,230

Świętokrzyskie Kielce Świętokrzyskie Oncology Centre 1555 465 136 2,170

Independent Public Healthcare Centre of the Ministry of Internal Affairs with Warmińsko-Mazurskie Warmińsko-Mazurskie Olsztyn 1580 231 - 1736 Oncology Centre

Centrum Medyczne HCP sp. zoo. Non-Public Healthcare Centre Centrum Medyczne HCP - Inpatient 1147 429 - 1250 treatment

Wielkopolskie Poznań Heliodor Święcicki Clinical Hospital at the Karol Marcinkowski Medical University - - 645 645

Karol Marcinkowski University Hospital of Lord’s Transfiguration - 4 - 4

Maria Skłodowska-Curie Wielkopolskie Oncology Centre 4173 742 - 4,506

Koszalin Euromedic Onkoterapia - International Oncology Centre 597 50 - 924 Zachodniopomorskie Szczecin Zachodniopomorskie Oncology Centre 2,525 297 - 2,699 Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In 2012, four facilities in Mazowieckie Voivodeship provided radiotherapy treatment to patients. Maria Skłodowska-Curie Institute of Oncology in Warsaw admitted 6,755 unique patients for teletherapy, 834 for brachytherapy and 1,562 for isotope therapy. Oncology Hospital in Wieliszew admitted 1,540 unique patients for teletherapy and 220 for brachytherapy. The patients admitted to the Military Institute of Medicine and the Central Clinical Hospital of the MSWiA have only undergone isotope treatment (165 and 99 patients respectively).

145 Teletherapy treatments in Poland

In the field of teletherapy in 2012, Polish facilities admitted over 56.5 thousand unique patients. Among these patients, almost 35.5 thousand underwent radical radiotherapy, almost 22.2 thousand – palliative radiotherapy, and slightly over 100 – intraoperative radiotherapy. Figure 153 shows the number of reported services of radical teletherapy, palliative teletherapy and the number of unique patients administered teletherapy treatment. In 2012, treatment providers reported over 37,000 radical teletherapy treatments and approx. 28,000 palliative teletherapy treatments. Two major service providers, i.e. Oncology Centres in Warsaw and Gliwice, admitted a total of 12.6 thousand patients, which accounted for over 22% of all patients administered teletherapy treatment in Poland. They reported 14.6 thousand services, which accounted for 22.5% of all teletherapy services. Figure 154 shows corresponding data arranged by the ratio of radical services performed to all teletherapy services, which, at the national level, amounted to approx. 0.57, which means that out of every 100 teletherapy services over 40 were reported as palliative services. It was found that, with few exceptions, smaller centres had the lowest share of radical services in all teletherapeutic services.

Figure 153: Number of reported radical and palliative teletherapy services and the

number of patients who received teletherapy (2012)

Number treatments of

Number of radical teletherapy treatments Number of unique patients (teletherapy)

Number of palliative teletherapy treatments

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

146 Figure 154: Number of reported radical and palliative teletherapy servives and the share

of radical treatments in all teletherapy services (2012)

Number treatments of Sharehealthcare of services radical

Number of palliative teletherapy treatments Number of radical teletherapy Share of radicaltreatments healthcare services in all teletherapy services (right axis) Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Mazowieckie Voivodeship, two facilities provided teletherapy treatments. Maria Skłodowska- Curie Institute of Oncology in Warsaw admitted almost 4.3 thousand unique patients for radical teletherapy and almost 2.6 thousand for palliative teletherapy. The facility reported approx. 4.35 thousand radical teletherapy treatments and approx. 3.4 thousand palliative teletherapy treatments. Maria Skłodowska-Curie Institute of Oncology in Warsaw is marked with numeral reference 1 in Figure 153, which means that this provider ranked first in Poland in terms of the number of unique patients admitted in 2012 (in the scope of teletherapy). In Figure 154, the Warsaw Oncology Centre is marked with numeral reference 9, which in turn means that it ranked ninth in Poland in terms of the share of radical teletherapy services in all teletherapy services. In Maria Skłodowska-Curie Institute of Oncology in Warsaw, every 56 out of 100 teletherapy services were radical in nature.

Another service provider to report teletherapy services in 2012 was Oncology Hospital in Wieliszew. In 2012, this service provider admitted approx. 980 patients for radical teletherapy and approx. 570 for palliative teletherapy. The facility reported approx. 990 radical teletherapy treatments and more than 780 palliative teletherapy treatments. In Figure 153, the Oncology Hospital in Wieliszew is marked with numeral reference 14, which means that out of 27 hospitals to have reported teletherapy services in 2012, it ranked 14th in terms of the number of unique patients admitted in this scope. In Figure 154, this facility is marked with numeral reference 11, which means that it ranked 11th in Poland in terms of the share of radical teletherapy services in all teletherapy services. Out of every 100 services in this field, 56 were radical services in the Oncology Hospital in Wieliszew.

In 2012, there were over 36.8 thousand radical teletherapy services and over 28 thousand palliative teletherapy services provided in Poland. Figure 155 shows the number of teletherapy services reported provided to inhabitants of Polish voivodeships (per 100 cancer patients). All

147 patients who used oncology-related services in the field of inpatient healthcare in 2012 were qualified as cancer patients. In order to ensure better comparability between voivodeships, the data was standardised for the cancer type and stage.

Figure 155: Number of (radical and palliative) teletherapy services per 100 cancer patients in Polish voivodeships – data standardised for cancer type and stage (2012)

Teletherapy utilisation rate

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In 2012 in Poland, slightly over 24 teletherapy services were reported per 100 cancer patients. Following data standardisation, the best access to the radiotherapy was observed in Śląskie (30.9 healthcare services per 100 cancer patients), Lubuskie (29.3), Kujawsko-Pomorskie (28.1) and Podkarpackie (27) Voivodeships. The median value for all Polish voivodeships was 23.9 teletherapy services per 100 cancer patients. This means that the rate was not higher than 23.9 in one half of the voivodeships analysed, and not lower than 23.9 in the other half. The lowest number of teletherapy services per 100 cancer patients (following the standardisation) was provided to the inhabitants of Świętokrzyskie Voivodeship (17.6 per 100 patients). Only slightly better situation was observed in Warmińsko-Mazurskie (18.1) and Łódzkie (19.3) Voivodeships. Mazowieckie Voivodeship ranked fourth in term of the lowest value of the analysed rate. In 2012, 10.8 person-day of hospitalisation for teletherapy was accounted for per one patient for whom teletherapy services were reported. Figure 156 shows the number of reported hospitalisation person-days per one patient receiving teletherapy oncology services in 2012 (utilisation rate of hospitalisation for teletherapy). As before, the data was standardised for cancer type and stage.

148 Figure 156: Utilisation rate of hospitalisation for teletherapy in Polish voivodeships – data standardised for cancer type and stage (2012)

Utilisation rate of hospitalisation for teletherapy

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The lowest reported number of person-days of hospitalisation for teletherapy treatment was observed in Śląskie (5.5), Łódzkie (8.7) and Mazowieckie (9.4) Voivodeships. The median for the voivodeships was 12 person-days per one patient receiving teletherapy services. The worst situation, i.e. the highest number of person-days of hospitalisation per one cancer patient was observed in Lubuskie (14.2), Podlaskie (13.8), Lubelskie (13.6) and Opolskie (13.1) Voivodeships.

The analysis of teletherapy services on the level of Polish counties reveals two types of correlation. First, the number of teletherapy services is characterised by a negative correlation relative to the distance of a county to the nearest linear particle accelerator (calculated as a straight-line distance between county cities). In general, it means that the further the patient lives from a facility with an installed accelerator, the less frequently he or she benefits from teletherapy. The linear correlation coefficient between the distance and the number of teletherapy services per 100 cancer patients was 0.38 on the national scale. The discussed correlation is shown on figure 157 (counties are marked with dots).

149 Figure 157: Correlation between the standardised number of (radical and palliative) teletherapy services per 100 cancer patients and the distance to the nearest facility with

a linear particle accelerator in Polish counties (2012).

(standardised)

per 100 cancer patients perpatients cancer 100 Number teletherapyservices of

Distance to the nearest facility with a linear particle accelerator (km) Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Also, importantly, the correlation between the distance to the nearest accelerator and the utilisation rate of hospitalisation for teletherapy is positive (Pearson’s correlation coefficient of 0.62). In other words, the further patients live from a facility with an accelerator, the longer they will be hospitalised for teletherapy procedures. The discussed correlation is shown on figure 158 (counties are marked with dots).

Figure 158: Correlation between the utilisation rate of hospitalisation for teletherapy and the distance to the nearest facility with a linear particle accelerator in Polish counties

(2012)

for(standardised) teletherapy Utilisationrate hospitalisation of

Distance to the nearest facility with a linear particle accelerator (km) Source: compiled by DAiS based on data provided by the KRN and the NFZ.

It follows from the correlations discussed above that, when it comes to using teletherapy services, the distance required to travel in order to undergo teletherapy is an important factor for patients to consider. The further patients live from a facility operating a linear particle accelerator, the less likely they are to use teletherapy services, and if they do, on average they will be hospitalised for a longer period. Teletherapy is a long-term treatment service that takes several weeks to implement. The need for daily commutes is troublesome for patients, which, in turn, can make them choose to stop the treatment. On the other hand, the need for hospitalisation of people travelling from remote counties generates additional costs. In order

150 to improve the situation, an increase in the number of facilities with the linear particle accelerators should be considered. A relevant analysis was presented in the chapter on forecasts.

Teletherapy services in the Voivodeship

In 2012, the inhabitants of Mazowieckie Voivodeship were cleared for over 5 thousand radical teletherapy treatments and almost 3.9 thousand palliative teletherapy treatments. Inhabitants of Mazowieckie Voivodeship mostly received treatment in Warsaw and in Wieliszew, but there were substantial groups of patients who also received treatment outside the voivodeship. Municipalities of teletherapy treatment for patients from Mazovian counties are shown in Figure 159. Facilities that admitted over 50 patients from Mazowieckie Voivodeship in 2012 are highlighted.

Figure 159: Municipalities of teletherapy treatment for patients from Mazovian counties (2012)

No. of patients per county: Patients treated in:

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Apart from a few exceptions in all Mazovian counties, the majority of patients receiving teletherapy services were treated in Warsaw. In the north-central counties of the voivodeship, a large share of patients was laso admitted to the Wieliszew Centre. Likewise, in the southern counties, a substantial share of patients was treated at the Maria Skłodowska-Curie Non-Public Oncology Hospital in Wieliszew. Patients from some counties located on the boundaries of Mazowieckie Voivodeship migrated in order to use teletherapy in facilities located in neighbouring voivodeships. In the north, inhabitants of the counties of Przasnysz, Ostrołęka and Mława chose to undergo teletherapy in Olsztyn. In the south-east, inhabitants of the counties of Łosice, Kozienice and Zwoleń often used teletherapy services in Lublin, inhabitants of north-western counties (of Żuromin, Sierpc, Płock, and Płock City) in Bydgoszcz, while

151 inhabitants of counties in the south (Radom City and counties of Radom, Przysucha, Szydłowiec, Zwoleń and Lipsko) in Kielce.

Patients inhabiting particular counties of Mazowieckie Voivodeship used radical and palliative teletherapy to a different degree. Figure 160 shows the number of radical teletherapy services per 100 cancer patients (data standardized for cancer type and stage).

Figure 160: Standardised number of radical teletherapy services per 100 cancer patients in Mazovian counties – data standardised for cancer type and stage (2012)

Utilisation rate of teletherapy treatments

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Regionwide, 12.5 radical teletherapy treatments per 100 patients were provided. Taking into account the standardisation for cancer type and stage, they were most used by the inhabitants of north-western counties: Sierpc, Płońsk, Ciechanów, Pułtusk, Nowy Dwór Mazowiecki, Legionowo and Wołomin County. The radical teletherapy utilisation rate for Mazowieckie Voivodeship was relatively high also in southern counties. The median value amounted to 12.9 radical teletherapy treatments per 100 cancer patients. The analysed rate values were the lowest in the north-eastern part of the region (Ostrołęka City, as well as the following counties: Ostrołęka, Przasnysz and Maków Mazowiecki). It follows from Figure 160 that a positive correlation between the distance from the accelerator and the teletherapy utilisation rate in Mazowieckie Voivodeship is to be expected.

The differences in the utilisation rate of radical radiotherapy between Mazovian counties imply that the distribution of counties with higher rates compared to their neighbours coincides with the network of the largest Warsaw access roads. The strip of counties with the highest values in the north-eastern part of the Voivodeship is crossed by national road no. 7 and the S10 road diverging from it in Płońsk. The counties of Wyszków and Ostrów Mazowiecka, also with locally high rate values, are crossed by the national road no. 8 (section E67 – Via Baltica), the counties

152 of Mińsk Mazowiecki, Siedlce and Siedlce City are crossed by the E30 road, and the counties of Otwock and Garwolin – by the national road no. 17. On the other hand, the counties of the southern part of the Voivodeship (Radom City and counties of Radom, Zwoleń, Przysucha and Białobrzegi) are at the junction of national roads no. 7 and No. 12 (allowing to quickly access both Warsaw and Kielce). In addition, the network of national roads described above coincides to a substantial degree with the railway network of Koleje Mazowieckie. In view of the observations above, it can be concluded that the radical teletherapy utilisation rate in Mazowieckie Voivodeship is strongly influenced by the development of infrastructure. The cancer patients inhabiting the counties crossed by main state roads (expressways at many sections) are able to reach a teletherapy provider (located in Warsaw, Wieliszew or Kielce) faster; thus, they use teletherapy more often.

Figure 161 shows the number of palliative teletherapy services per 100 cancer patients inhabiting a particular county. Again, in order to ensure better comparability between counties, the data was standardised for the cancer type and stage.

Figure 161: Standardised number of palliative teletherapy services per 100 cancer patients in Mazovian counties – data standardised for cancer type and stage (2012)

Utilisation rate of palliative teletherapy

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Regionwide, 9.6 palliative teletherapy treatments per 100 patients were provided. They were most likely to be used by the inhabitants of counties surrounding Warsaw and counties of Węgrów, Ostrów Mazowiecka, Żuromin and Szydłowiec. The median value for Mazovian counties amounted to 9.7 palliative teletherapy treatments per 100 cancer patients. The lowest values of this ratio were recorded in the north-eastern (of Ostrołęka and Maków), western (of Płock and Gostynin) and eastern (of Łosice, Siedlce, Garwolin, Otwock and Siedlce City) counties of the Voivodeship. It clearly follows from Figure 161 that there is a negative

153 correlation between the distance between the county and the nearest facility with a linear accelerator and the utilisation rate of palliative teletherapy. Comparison of Figures 160 and 161 indicates that in some parts of the Voivodeship radical and palliative teletherapy are interchangeable in nature. This is well illustrated by a group of eastern counties: Siedlce City and the counties of Siedlce, Otwock and Garwolin have locally high values of utilisation rate of radical teletherapy and locally low values of utilisation rate of palliative teletherapy. The situation is opposite in the counties neighbouring with those listed above, i.e. the counties of Kozienice, Sokołów Podlaski and Węgrów (locally high utilisation rateof palliative teletherapy and low of radical teletherapy). The situation looks similar as regards the north-eastern part counties of the voivodeship. The county of Żuromin had a high utilisation rate of palliative teletherapy and low of radical teletherapy. In contrast, counties located near the county of Żuromin (those of Mława, Sierpc, Płońsk, Płock and Płock City) had a high utilisation rate of radical teletherapy and low utilisation rate of palliative teletherapy. As regards the analysis of Figures 160 and 161, the north-eastern region of Mazowieckie Voivodeship should be noted. The counties of Ostrołęka and Maków were in the first (lowest) quartile of Mazovian counties in terms of both types of teletherapy discussed. These counties form the so-called "white spot", i.e. a region with significantly limited access to teletherapy services.

For better illustration of the correlation between the rates and the distance from facilities providing teletherapy services visible in Figures 160 and 161, Figure 162 shows the relation between the number of radical and palliative teletherapy services per 100 cancer patients (after standardization, in total), and the distance between Mazovian counties and the cities nearest thereto, in which linear accelerators were located (wherein such cities did not necessarily have to be located in the Voivodeship at issue). The distances between counties were calculated in a straight line between county cities. Counties are marked with dots.

Figure 162: Correlation between the standardised number of (radical and palliative) teletherapy services per 100 cancer patients and the distance to the nearest facility with

a linear particle accelerator in Mazovian counties (2012)

100 (standardised) patients cancer Number teletherapyper services of

Distance to the nearest facility with a linear particle accelerator (km) Source: compiled by DAiS based on data provided by the KRN and the NFZ.

154 In Figure 162, the dotted line shows a linear trend curve. There is a clear negative correlation between the distance from the nearest linear accelerator and the number of services per 100 cancer patients. The linear correlation rate between these variables was -0.45. It should therefore be stated, assuming a linear correlation rate as the reference, that the problem of access to teletherapy services is more tangible in Mazowieckie Voivodeship than in the whole country. Figure 162 also shows that in the case of the discussed correlation in Mazowieckie Voivodeship there are significant deviations from the trend curve between counties. The counties located at a similar distance from each other can substantially differ in terms of teletherapy utilisation rate. The high values of the remaining, especially as regards the counties that are remote from facilities providing teletherapy services, may be explained by the differences in the development of road infrastructure between counties as discussed above. For example, the counties of Węgrów, Ostrów Mazowiecka and Sokołów Podlaski, located on the eastern border of Mazowieckie Voivodeship and neighbouring with each other, are, in a straight line, at a similar distance from the nearest city with a linear accelerator (Węgrów – 70 km, Ostrów Mazowiecka – 77 km, Sokołów Podlaski – 87 km), and the standardized teletherapy utiisation rates recorded there amounted to approx. 23, 28 and 19 services per 100 cancer patients, respectively. This can be explained by the fact that an important national road (No. 8) crosses the county of Ostrów Mazowiecka, while there is no road providing an equally fast access to Warsaw in the other counties.

In 2012, nearly 62,000 person-days of hospitalisation for teletherapy were reported for the inhabitamts of Mazowieckie Voivodeship, i.e. an average of 8 per patient using teletherapy services (without standardization). The number of person-days of hospitalisation for teletherapy per one patient inhabiting a particular Mazovian county is shown in Figure 163. The rates were again standardised.

155 Figure 163: Utilisation rate of hospitalisation for teletherapy in Mazovian counties – data standardised for cancer type and stage (2012)

Utilisation rate of hospitalisation for teletherapy

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 163 clearly indicates that the correlation observed across the country applies to Mazowieckie Voivodeship, i.e. a positive correlation between the distance of the county from the city in which the facility providing teletherapy services was located (i.e., in Mazowieckie Voivodeship, Warsaw and Wieliszew (the county of Legionowo) and the number of person- days of hospitalisation for teletherapy per patient using teletherapy services. The counties neighbouring with Warsaw and the county of Legionowo had the lowest values of the hospitalisation utilisation for teletherapy, while the highest values were recorded in counties that were the most remote from Warsaw (in the east, south and north-west of the Voivodeship). The median for Mazovian counties was 10.7 person-days of hospitalization for teletherapy per one cancer patient receiving teletherapy services.

For better illustration of the correlation observed, Figure 164 shows the correlation between the number of person-days of hospitalisation per patient (after standardisation) using oncology services in the scope of teletherapy, and the distance between Mazovian counties and the cities nearest thereto where linear accelerators were located (also in neighbouring voivodeships). The distances between counties were calculated in a straight line between county cities. Each dot denotes one county.

156 Figure 164: Correlation between the utilisation rate of hospitalisation for teletherapy and the distance to the nearest facility with a linear particle accelerator in Mazovian counties

(2012)

teletherapy(standardised) Utilisation rate of hospitalisation for Utilisationrate for hospitalisation of

Distance to the nearest facility with a linear particle accelerator (km) Source: compiled by DAiS based on data provided by the KRN and the NFZ.

In Figure 164, the dotted line shows a linear trend curve. This curve has a high, positive direction-based rate. The correlation rate between the distance and the inpatient teletherapy treatment rate amounted to 0.79 for Mazovian counties. Taking this rate as a reference, it should be stated that the correlation between the discussed variables is greater for Mazovian counties than on the national scale. Figure 164 shows much smaller deviations of the observations (of counties) from the trend curve compared to Figure 162.

To sum up, Mazowieckie Voivodeship had a relatively low accessibility to teletherapy services compared to the whole country, as it ranked fourth with the lowest teletherapy utilisation rate standardised between voivodeships (21.4 services per 100 cancer patients). On the other hand, it also ranked the third voivodeship in Poland in terms of the standardized utilisation rate of hospitalisation for teletherapy (9.4 person-days of hospitalisation for teletherapy per patient receiving respective treatment). There is a clear correlation in Mazowieckie Voivodeship between the distance between the county and the nearest facility with a linear accelerator and the utilisation rates of teletherapy and hospitalisation for teletherapy. Assuming the order based on the Pearson's correlation coefficient, it should be stated that these correlations are more pronounced in Mazowieckie Voivodeship compared to the whole country. The correlation coefficient between said distance and the teletherapy utilisation rate amounted to -0.45 in Mazowieckie Voivodeship and to -0.38 nationwide.

In turn, the correlation coefficient between the distance and the inpatient teletherapy treatment rate amounted to 0.62 for Poland, and 0.79 for Mazovian counties.

157 2.1.7 Hospitalisation – minor up to 18 years of age

Healthcare providers in Poland

In 2012, 166 hospitals provided cancer treatment for people under 18 years of age within the scope of analysed cancer group in Poland33. Figure 165 illustrates the geographic distribution of those healthcare providers, accurate to a county34.

Figure 165: Geographical distribution of hospitals providing cancer treatments to patients of up to 18 years of age

Number of hospitals

No hospital 1 [2-4) [4-6) [6-10) [10-15)

Source: compiled by DAiS based on data provided by the NFZ.

In most counties, no hospital reported oncology-related services for patients under 18 years of age. Apart from counties, where there are no providers reporting services for underage cancer patients, there are most counties with one provider of this type. A larger number was to be found only in large cities, usually capitals of voivodeships. Most providers are located in Warsaw (15).

Out of 166 hospitals analysed accounting for cancer treatments, only 15 healthcare providers treated more than 2% of cancer patients below 18 years of age on the national scale35. The names of these facilities together with the number of patients of up to 18 years of age treated in 2012 were listed from the highest values (Table 20). In most facilities, very few patients were

33 According to the definition above, the analysis covered cancer-related treatments without oncohematology and without skin cancers excluding melanoma. For the sake of clarity, these treatments will be hereinbelow referred to as cancer treatments. 34 A provider with two facilities in one county is indicated once on the map, whereas if it has branches in different counties, it is included in each of these. In other words, a provider is counted once in each county. 35 The percentage of patients on a national scale is defined as the number of patients admitted with a cancer diagnosis analysed versus the unique number of cancer patients in Poland. In other words, the patient admitted to two different hospitals will be included in the numerator in each of them, but only once in the nominative. Accordingly, the sum of this variable is greater than 100%.

158 admitted (less than 5). Probably, in most hospitals with fewer patients, these are people suffering from cancer, who were admitted to these facilities for another reason (e.g. due to various types of post-chemotherapy complications). Importantly, in 2012, there were 245 cancer patients under the age of 18 years old recorded in the region.

Based on the analysis of data from Table 20, it was concluded that within the analysed period most patients up to 18 years of age were treated in the Children’s Memorial Health Institute in Warsaw. The number of patients at the facility was 470, accounting for 21% of patients in the whole country.

The next two largest entities in terms of the number of patients up to 18 years of age for whom oncology-related services were provided are the Independent Public Clinical Hospital No. 1 in Wrocław and the Institute of Mother and Child in Warsaw. The first one admitted 263 patients (11.7%), and the other – 203 patients (9.1%).

The share of patients aged below 18 of more than 6% in the national scale was observed in six more institutions. These included: Independent Public Clinical Hospital No. 6 of the Upper- Silesian Child Healthcare Centre in Katowice (7%), Independent Public Healthcare Centre Maria Konopnicka Clinical Hospital No. 4 of the Medical University in Łódź (6.9%),Children's Hospital in Kraków (6.6%), Karol Jonscher Clinical Hospital at the Karol Marcinkowski Medical University in Poznań (6.5%), Professor Tadeusz Sokołowski Independent Public Clinical Hospital at PUM (6.3%), University Clinical Centre in Gdańsk (6.1%). The other facilities admitted fewer patients.

159 Table 20: Hospitals treating over 2% of patients aged below 18 years, diagnosed with cancer in Poland (2012)

Cumulative Number of Percentage Item Name of the treatment provider percentage of patients of patients patients

1 Children’s Memorial Health Institute in Warsaw 470 21.0% 21.0%

2 Independent Public Clinical Hospital No. 1 in Wrocław 263 11.7% 32.7%

3 Institute of Mother and Child in Warsaw 203 9.1% 41.8%

Independent Public Clinical Hospital No. 6 of the Górnośląskie 4 Child Healthcare Centre in Katowice 156 7.0% 48.7%

Independent Public Healthcare Centre Maria Konopnicka Clinical 5 Hospital No. 4 of the Medical University in Łódź 155 5.9% 55.7%

6 Children Hospital in Kraków 147 5.6% 62.2%

Karol Jonscher Clinical Hospital at the Karol Marcinkowski 7 Medical University in Poznań 146 5.5% 68.7%

Professor Tadeusz Sokołowski Independent Public Clinical 8 Hospital at PUM 141 5.3% 75.0%

9 University Clinical Centre in Gdańsk 136 6.1% 81.1%

Tadeusz Marciniak Lower Silesian Specialist Hospital - 10 Emergency Medical Centre 108 4.8% 85.9%

11 Antoni Jurasz University Hospital No. 1 in Bydgoszcz 98 4.4% 90.3%

Ludwik Zamenhof University Paediatric Clinical Hospital in 12 Białystok 76 3.4% 93.7%

13 Mikołaj Kopernik Hospital in Gdańsk 67 3.0% 96.7%

14 Professor Gębala Paediatric Clinical Hospital in Lublin 65 2.9% 99.6%

15 University Hospital Healthcare in Kraków 49 2.2% 101.8%

TOTAL (unique patients): 2240 100.0% X

Geographical distribution of hospitals providing treatment to more than 2% of cancer patients below 18 years of age (cf. Table 20) is shown with an accuracy to a county in Figure 166. The analysed hospitals are located only in large cities, usually capitals of particular voivodeships. Out of 15 of these hospitals, Warsaw, Kraków, Wrocław and Gdańsk each had two.

160 Figure 166: Geographic distribution of hospitals treating over 2% of patients aged below 18 years, diagnosed with cancer in Poland (2012)

Number of hospitals

No hospital 1 2

Source: compiled by DAiS based on data provided by the NFZ.

Healthcare providers in the voivoideship

In Mazowieckie Voivodeship in 2012, hospital oncology-related services for patients under 18 years of age were provided by 29 hospitals, with only two of them, however, treating more than 35 patients per year. These were the Children’s Memorial Health Institute in Warsaw and the Institute of Mother and Child in Warsaw. These facilities more analysed in greater detail hereinbelow. Probably, in most hospitals with fewer patients, these are people suffering from cancer, who were admitted to these facilities for another reason (e.g. due to various types of post-chemotherapy complications).

Since there are two hospitals in the voivoideship that admit a substantial number of underage cancer patients, and in several voivodeships there is no such hospital, the structure of their patients should be analysed in terms of their voivodeship of origin.

Table 21 contains data on the number of patients up to 18 years of age who received treatment at the Children’s Memorial Health Institute in Warsaw by their voivodeship of origin. The percentage of patients from a voivodeship treated in the analysed hospital is also indicated. Voivodeships were ranked by the number of patients. Some of the patients have no voivodeship of origin coded – relevant information is indicated at the bottom of the table.

161 Table 21: Number of patients up to 18 years of age at the Children’s Memorial Health Institute in Warsaw by their voivodeship of residence (2012)

Voivodeship Number of patients % of patients from the voivodeship

Mazowieckie 117 47.8%

Warmińsko-Mazurskie 43 37.7%

Podkarpackie 34 35.1%

Lubelskie 30 23.5%

Wielkopolskie 26 10.7%

Podlaskie 20 19.8%

Łódzkie 19 3.3%

Kujawsko-Pomorskie 17 11.6%

Pomorskie 16 7.4%

Dolnośląskie 14 5.6%

Świętokrzyskie 13 17.8%

Śląskie 12 4.9%

Zachodniopomorskie 11 6.2%

Lubuskie 10 11.5%

Małopolskie 8 5.4%

Opolskie 6 6.4%

no data 74 25.4%

TOTAL 470 X Source: compiled by DAiS based on data provided by the NFZ.

The Children’s Memorial Health Institute in Warsaw provides treatment to 47.8% cancer patients up to 18 years of age from Mazowieckie Voivodeship, 37.7% from Warmińsko- Mazurskie Voivodeship, 35.1% from Wielkopolskie Voivodeship and 23.6% of patients from Lubelskie Voivodeship.

Table 22, on the other hand, contains corresponding data for the Institute of Mother and Child in Warsaw.

162 Table 22: Number of patients up to 18 years of age at the Institute of Mother and Child in Warsaw by their voivodeship of residence (2012)

Voivodeship Number of patients % of patients from the voivodeship

Mazowieckie 42 17.1%

Wielkopolskie 22 3.1%

Małopolskie 14 3.5%

Śląskie 14 5.7%

Podkarpackie 13 13.4%

Łódzkie 12 6.2%

Pomorskie 11 5.1%

Lubelskie 10 7.3%

Kujawsko-Pomorskie 3 6.2%

Świętokrzyskie 3 12.3%

Dolnośląskie 7 2.8%

Warmińsko-Mazurskie 6 5.3%

Opolskie 5 5.3%

Podlaskie 4 4.0%

Zachodniopomorskie 4 2.3%

Lubuskie 3 3.4%

no data 18 6.2%

TOTAL 203 X Source: compiled by DAiS based on data provided by the NFZ.

The Institute of Mother and Child in Warsaw provides treatment to 17.1% cancer patients up to 18 years of age from Mazowieckie Voivodeship, 9.1% from Wielkopolskie Voivodeship and 9.5% of patients from Małopolskie Voivodeship.

2.2 Specialist Outpatient Care

Healthcare providers in Poland

In 2012, in Poland there were 4,603 Specialist Outpatient Care Facilities (AOS) where oncology-related treatment was provided. Figure 167 shows the geographic distribution thereof. Colours on the map indicate the number of centres in a selected county. The darker the colour is, the more centres are located in a given county. A healthcare provider with many centres within one county was counted only once. If a healthcare provider had centres in different counties, then it was counted in each of them. The map contains only specialist outpatient care facilities having a contract with the public payer (NFZ).

163 Figure 167: Counties with specialist outpatient care facilities treating cancer patients in Poland (2012)

Number of AOS

no AOS (1-3) [3-10) [10-20) [20-30) [30-138)

Source: compiled by DAiS based on data provided by the NFZ.

Across the country there were three counties with no specialist outpatient care facility to provide oncology-related services, i.e. the counties of Łomża, Przemyśl and Skierniewice. Most facilities were located in large cities: Kraków (99), Łódź (109), Wrocław (118), Poznań (118) and Warsaw (138). Also, AOS facilities are concentrated to a greater degree in the central and southern regions of the country, especially in Śląskie and Małopolskie Voivodeships.

The average number of AOS facilities per county was 12.88, and the median was 9. This means that there were nine or less facilities on the territory of one half of the counties.

Healthcare providers in the voivoideship

In Mazowieckie Voivodeship, in 2012, oncology-related outpatient services were provided by 468 AOS facilities. Figure 168 shows the geographic distribution of these facilities in the region. The values on the map indicate the number of service providers in a county. The greatest number of AOS facilities was situated in Warsaw (138), which accounted for 29.5% of all oncology facilities in the region. A relatively high number of facilities were located in the central part of the region. In 7 counties, there were less than three AOS facilities.

164 Figure 168: Counties with specialist outpatient care facilities treating cancer patients in Mazowieckie Voivodeship (2012)

Number of AOS in counties

Source: compiled by DAiS based on data provided by the NFZ.

Figure 169 shows migrations of patients of specialist outpatient facilities providing cardiology- related services to Mazowieckie Voivodeship. 89.0% of patients treated in Mazowieckie Voivodeship were inhabitants thereof. The arrows represent the share of patients from a voivodeship expressed as the number of incoming patients in total. For legibility purposes, a 5% cut-off was applied. This means that the map does not show the migration from voivodeships inhabitants of which constituted less than 5% of all the patients from other voivodeships treated in Mazovian region. In total, 13,268 patients migrated to entities in Mazowieckie Voivodeship area. The highest share of these migrations was accounted for by inhabitants of Podkarpackie, Warmińsko-Mazurskie, Podlaskie and Łódzkie Voivodeships.

165 Figure 169: Migrations of patients using specialist outpatient care services to Mazowieckie Voivodeship (2012)

% of all incoming patients

Share (%) of patients from the voivodeship

Source: compiled by DAiS based on data provided by the NFZ.

Figure 170 shows migrations of patients of specialist outpatient facilities providing cardiology- related services from Mazovian counties. The values symbolised by the colours of counties indicate what percentage of all patients from a county received treatment in it. The arrows complement the values represented by the colours in the map up to the value of 100%. Thus, 94.39% of patients from Warsaw received treatment in the local facilities. As for Figure 4, a cut-off has been defined. For this map, it was 10%.

Figure 170: Migrations of patients using specialist outpatient care services from Mazovian counties (2012)

% of patients from the county admitted in outpatient mode in the county % of patients admitted in outpatient mode

Source: compiled by DAiS based on data provided by the NFZ.

166 The map shows a clear trend of patients migrating to Warsaw. It is the main, but not the only, destination in Mazowieckie Voivodeship. To a lesser extent, people migrated to Płock, Radom and Siedlce.

Figure 171 presents major AOS facilities providing oncology-related services in Mazowieckie Voivodeship. Most (8) of these were located in Warsaw. Moreover, two were located in the county of Legionowo and in Radom and Płock each. The counties of Ciechanów, Grójec and Siedlce City each had one.

Figure 171: AOS facilities treating more than 2% of all unique cancer patients in Mazowieckie Voivodeship (2012)

Number of major AOS in counties

Source: compiled by DAiS based on data provided by the NFZ.

Table 23 lists the names of 50 facilities to have reported the largest number of oncology-related services. They are ranked by the number of cancer patients admitted. Blue colour marks the facilities in which the share of cancer patients regionwide exceeded 1%. 36

The largest group of cancer patients was admitted to Maria Skłodowska-Curie Institute of Oncology in Warsaw. Their number, 53,708, constituted 49.63 % of all unique cancer patients of the specialist outpatient care facilities in Mazowieckie Voivodeship. Another facility, Magodent Spółka z ograniczoną odpowiedzialnością, admitted 7,462 patients (6.89%). The Military Institute of Medicine ranked third with 4,764 cancer patients (4.4%) admitted.

36 The percentage of patients on a regional scale is defined as the number of patients admitted with a cancer diagnosis analysed versus the unique number of cancer patients in a voivodeship. Accordingly, the sum of this variable is greater than 100%. This is due to the fact that a patient admitted in two different centres was included in a numerator twice - for both centres, but only once in the nominative.

167 Table 23: AOS entities admitting most cancer patients in Mazowieckie Voivodeship (2012)

item Name of the treatment provider Number Share of of patients in patients the voivoideship

1 MARIA SKŁODOWSKA-CURIE INSTITUTE OF ONCOLOGY 53708 49.63

2 MAGODENT SPÓŁKA Z OGRANICZONĄ ODPOWIEDZIALNOŚCIĄ 7462 6.89

3 MILITARY INSTITUTE OF MEDICINE 4764 4.4

4 CENTRAL CLINICAL HOSPITAL OF THE MINISTRY OF THE INTERIOR AND 4469 4.13 ADMINISTRATION IN WARSAW

5 MAZOVIAN SPECIALIST HOSPITAL IN RADOM 3341 3.09

6 REGIONAL POLYCLINICAL HOSPITAL IN PŁOCK 3184 2.94

7 "ZDROWIE" MEDICAL CENTRE/ONCOLOGY HOSPITAL IN WIELISZEW/CLINIC 2979 2.75 OF THE ONCOLOGY HOSPITAL IN WIELISZEW

“ATTIS” THERAPEUTIC, REHABILITATION AND OCCUPATIONAL MEDICINE 2694 2.49 8 CENTRE

9 MARIA SKŁODOWSKA-CURIE NON-PUBLIC ONCOLOGY HOSPITAL IN 2515 2.32 WIELISZEW

10 PUBLIC PAEDIATRIC CENTRAL CLINICAL HOSPITAL 2513 2.32

11 INFANT JESUS CLINICAL HOSPITAL 2336 2.16

12 INSTITUTE OF TUBERCULOSIS AND LUNG DISEASES 2310 2.13

13 MAZOWIECKI SZPITAL WOJEWÓDZKI W SIEDLCACH SP. Z O.O. 1888 1.74

14 DR TYTUS CHAŁUBIŃSKI SPECIALIST HOSPITAL IN RADOM 1650 1.52

15 REGIONAL SPECIALIST HOSPITAL IN CIECHANÓW 1613 1.49

16 JÓZEF PSARSKI MAZOVIAN SPECIALIST HOSPITAL IN OSTROŁĘKA 1578 1.46

17 JERZY POPIEŁUSZKO BIELAŃSKI HOSPITAL – INDEPENDENT PUBLIC 1563 1.44 HEALTHCARE CENTRE

18 JERZY PETZ MEDIQ NON-PUBLIC HEALTHCARE CENTRE 1476 1.36

19 HOLY FAMILY SPECIALIST HOSPITAL INDEPENDENT PUBLIC HEALTHCARE 1292 1.19 CENTRE

20 EUROPEJSKIE CENTRUM ZDROWIA OTWOCK SP. Z O.O. 1232 1.14

PROFESSOR WITOLD ORŁOWSKI INDEPENDENT PUBLIC CLINICAL 1.13 21 HOSPITAL OF THE MEDICAL CENTRE FOR POSTGRADUATE EDUCATION IN 1221 WARSAW

22 MAZOWIECKI SZPITAL BRÓDNOWSKI W WARSZAWIE SP. Z O.O. 1154 1.07

23 “CEPELEK” CENTRAL MILITARY OUTPATIENT CLINIC INDEPENDENT PUBLIC 1139 1.05 HEALTHCARE CENTRE

168 24 BATTLE OF WARSAW 1920 MEDICAL CENTRE IN RADZYMIN – INDEPENDENT 1083 1 PUBLIC COMPLEX OF HEALTHCARE FACILITIES

25 JOHN PAUL II INDEPENDENT PUBLIC SPECIALIST WESTERN HOSPITAL 993 0.92

TRANSFIGURATION HOSPITAL IN WARSAW INDEPENDENT PUBLIC 924 0.85 26 HEALTHCARE CENTRE

27 OUTPATIENT HEALTHCARE CENTRE FOR ŻOLIBORZ, BIELANY AND 890 0.82 ŁOMIANKI

28 NUKLEOMED KRZYSZTOF TOTH NON-PUBLIC HEALTHCARE CENTRE 792 0.73

29 HEALTHCARE CENTRE NON-PUBLIC HEALTHCARE CENTRE 782 0.72

30 CENTRUM MEDYCZNE ENEL-MED SPÓŁKA AKCYJNA 774 0.72

31 LUX MED DIAGNOSTYKA SPÓŁKA Z OGRANICZONĄ ODPOWIEDZIALNOŚCIĄ 755 0.7

32 ENDOMED JANUSZ ROMANOWSKI SPÓŁKA JAWNA 681 0.63

33 “CENTRUM” NON-PUBLIC HEALTHCARE CENTRE 670 0.62

34 “MEDICA” SPECIALIST DOCTORS' PRACTICE NON-PUBLIC HEALTHCARE 576 0.53 CENTRE

35 RAFAŁ MASZTAK GROCHÓW HOSPITAL INDEPENDENT PUBLIC 563 0.52 HEALTHCARE CENTRE

36 INDEPENDENT PUBLIC COMPLEX OF HEALTHCARE FACILITIES IN OSTRÓW 550 0.51 MAZOWIECKA

37 MIĘDZYLESIE SPECIALIST HOSPITAL IN WARSAW 547 0.51

38 PRINCESS ANNA MAZOWIECKA PUBLIC TEACHING HOSPITAL 543 0.5

39 WARSZAWA WOLA – ŚRÓDMIEŚCIE INDEPENDENT PUBLIC HEALTHCARE 537 0.5 CENTRE

40 JÓZEF PIŁSUDSKI INDEPENDENT PUBLIC COMPLEX OF HEALTHCARE 537 0.5 FACILITIES IN PŁOŃSK

41 WARSZAWA BEMOWO-WŁOCHY HEALTHCARE FACILITY 487 0.45

42 INDEPENDENT PUBLIC COMPLEX OF HEALTHCARE FACILITIES IN 486 0.45 KOZIENICE

43 WARSZAWA PRAGA–PÓŁNOC INDEPENDENT PUBLIC COMPLEX OF 481 0.44 OUTPATIENT HEALTHCARE FACILITIES

44 SOCHACZEW COUNTY HOSPITAL HEALTHCARE COMPLEX 464 0.43

45 WŁODZIMIERZ ROEFLER RAILWAY HOSPITAL IN PRUSZKÓW 453 0.42

46 INDEPENDENT PUBLIC COMPLEX OF HEALTHCARE FACILITIES IN 446 0.41 PRZASNYSZ

47 MAZOVIAN CENTER FOR TREATMENT OF LUNG DISEASES AND 444 0.41 TUBERCULOSIS

48 WARSZAWA–TARGÓWEK INDEPENDENT PUBLIC COMPLEX OF 429 0.4 OUTPATIENT HEALTHCARE FACILITIES

169 49 DR ANNA GOSTYŃSKA WOLA HOSPITAL INDEPENDENT PUBLIC 421 0.39 HEALTHCARE CENTRE

50 COMPLEX OF PUBLIC HEALTHCARE FACILITIES IN OTWOCK 413 0.38 Source: compiled by DAiS based on data provided by the NFZ.

2.3 Positron Emission Tomography (PET)

In 2012, Positron Emission Tomography (PET) services under SOK37 were reported by 18 service providers in 11 voivodeships, of which 3 in Mazowieckie Voivodeship. Accordingly, in many cases inter-voivodeship patient migrations for receiving the service occurred. In Mazowieckie Voivodeship, 5,745 imaging procedures in 5192 unique patients were reported to the Fund in 2012. Of these, 3772 services (3432 patients) related to patients from this Voivodeship38. Mazowieckie Voivodeship was the destination of patients migrating from all voivodeships, in particular from Lubelskie Voivodeship (668 services), Podlaskie Voivodeship (457 services) and Łódzkie Voivodeship (189 services). (cf. Table 24). Moreover, patients from Mazowieckie Voivodeship were also reported in other facilities (336 services).

Table 24: Migrations from and to Mazowieckie Voivodeship in order to receive a PET scan (2012)

voivodeship Voivodeship of origin of patients Voivodeship of treatment of patients reported in Mazowieckie from Mazowieckie Voivodeship Voivodeship Dolnośląskie 38 4 Kujawsko-Pomorskie 30 100 Lubelskie 668 6 Lubuskie 17 Łódzkie 189 11 Małopolskie 48 7 Mazowieckie 3,772 3,772 Opolskie 18 Podkarpackie 107 Podlaskie 457 Pomorskie 45 3 Śląskie 90 21 Świętokrzyskie 62 146 Warmińsko-Mazurskie 109 26 Wielkopolskie 56 12 Zachodniopomorskie 39 Source: compiled based on data provided by the NFZ

37 PET scans are reported to the fund under Services Contracted Separately (SOK). If the service provider performed a PET scan (as part of hospitalisation/radiotherapy treatment) and did not report it to the National Health Fund, it is not included here. Due to the high pricing of the service (more than 3.5 thousand), such situations should not be frequent. 38 If the patient’s TERYT code was not reported (TERYT code was not assigned to the patient in the Central Registry of Insured Persons), TERYT code of the service provider was assigned (the patient has not migrated).

170 2.4 Primary Care (POZ)

In May 2015, Mazowieckie Voivodeship maintained 678 registered primary care centres. Figure 172 shows the number of facilities providing primary care services in selected Mazovian counties. Most facilities providing primary care services were located in Warsaw (129).

Figure 172: Number of primary care facilities in Mazovian counties (2015)

Number of primary care facilities

Source: compiled by DAiS based on data provided by the NFZ.

Analysis of Provided Services

Table 25 shows the number of services provided by primary care physicians in 2012 to inhabitants of Mazowieckie Voivodeship, including selected age groups. Figure 173 shows this phenomenon in percentages. Among all service recipients, women prevail in all age groups, except the youngest group where men are in majority. For 65+ age group this share amounted to 65%.

Table 25: Structure of provided healthcare services by gender and age groups in Mazowieckie Voivodeship (2012)

0-6 7-19 20-39 40-65 65+ total

Total 1,659,004 1016 845 1474 445 3,877,069 2889343.00 10,916,706

Female 788,815 516,836 855,586 2,292,657 1,945,093 6,398,988

Male 870,188 500,009 618,859 1584 411 944,250 4,517,717 Source: compiled by DAiS based on data provided by the NFZ.

171 Figure 173: Structure of provided healthcare services by age groups in Mazowieckie Voivodeship (2012)

Source: compiled by DAiS based on data provided by the NFZ.

Figure 174: Structure of provided healthcare services by gender and age groups in Mazowieckie Voivodeship (2012)

Female Male

Source: compiled by DAiS based on data provided by the NFZ.

In Mazowieckie Voivodeship, over 60% of all individuals who were provided with primary care physician services were above 40 years of age.

Table 26 shows health service utilisation rate in selected age groups. The average number of services per one resident in Mazowieckie Voivodeship is 4.3. Women receive healthcare services more often (5.3 services on average) than men (3.4 services per inhabitant).

Table 26: Utilisation rate of primary healthcare services by age and gender groups in Mazowieckie Voivodeship (2012)

0-6 7-19 20-39 40-65 65+ average

Total 9.58 3.20 1.97 4.24 7.79 4.32

Female 8.87 З.17 2.24 5.25 14.60 5.32

Male 10.33 3.23 1.69 3.31 3.97 3.42 Source: compiled by DAiS based on data provided by the NFZ.

Figures show the structure and number of services per number of inhabitants and POZ entities.

172 The highest share, as compared to all services provided to inhabitants of Mazowieckie Voivodeship, is in Warsaw (25.8%), while the lowest in Zwoleń county (0.7%). Figure 175).

The highest number of primary care services is used by the inhabitants of the county of Łosice (4.4). The lowest number of primary care services per person is observed in the following counties: Wołomin, Warsaw-West, Radom and Radom City (2.9).

Figure 175: Number of primary care services of a physician per inhabitant in Mazovian counties (2012)

Number of healthcare services per inhabitant

Source: compiled by DAiS based on data provided by the NFZ.

The number of services per one entity providing primary care services varies between the counties of Mazowieckie Voivodeship. On average, the highest number of primary healthcare treatments was provided in Gostynin County (57 thousand), whereas the lowest in Lipsko County (16.1 thousand). Figure 176).

173 Figure 176: Number of primary care services (in thousands) of a physician per one primary care facility in Mazovian counties (2012)

Number of primary care services

Source: compiled by DAiS based on data provided by the NFZ.

2.5 Medical Staff39

Surgical oncologists

In 2012, there were 88 oncology surgeons working in Mazowieckie Voivodeship registered in the NIL database40. They represented approx. 18% of all oncology surgeons working in Poland. This was the 1st highest value countrywide (Figure 177).

39 The Ministry of Health addresses special acknowledgements to the Supreme Medical Council for sharing data on the medical staff which were used to prepare the analyses contained in this chapter. 40 The number of physicians is not an unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation, if the doctor has several specialisations, he is taken into account in each of them.

174 Figure 177: Number of surgical oncologists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

In Mazowieckie Voivodeship, in 2012, the number of oncology surgeons per 100 thousand adults was 2.06. This was the 4th highest value countrywide (Figure 178).

Figure 178: Number of surgical oncologists per 100,000 adults in individual

voivodeships in 2012

people over 18 years of age people18 of over years Number physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

In 2012, an oncology surgeon in Mazowieckie Voivodeship had a contract signed with more than two (2.57) healthcare providers contracted with the public payer. This was the 3rd highest result countrywide (Figure 184).

175

Figure 179: Number of contracts with healthcare providers contracted with the public payer per one surgical oncologist in individual voivodeships in 2012

Average number of contracts per 1 physician

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and the NFZ

In 2012, most oncology surgeons practising in Mazowieckie Voivodeship were in the 45-50 age range. The median age for the Voivodeship was 52 years and it was higher by one year than the Polish median (Figure 180 and Figure 181).

176

Figure 180: Age structure of surgical oncologists in Poland in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 181: Age breakdown of oncology surgeons in Mazowieckie Voivodeship in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Oncological gynecologists

In 2012, there were 24 oncological gynecologists working in Mazowieckie Voivodeship registered in the NIL database41. They represented approx. 16% of all oncological gynecologists working in Poland. This was the 1st highest value countrywide (Figure 182).

41 The number of physicians is not a unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation; if the doctor has several specialisations, he is taken into account in each of them.

177 Figure 182: Number of gynaecologic oncologists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

In Mazowieckie Voivodeship, in 2012, the number of oncological gynecologists per 100,000 adults was 0.56. This was the 7th highest value countrywide (Figure 183).

Figure 183: Number of gynaecologic oncologists per 100,000 adults in individual

voivodeships in 2012

people over 18 years of age people18 of over years Number physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

In 2012, an oncological gynecologist in Mazowieckie Voivodeship had a contract signed on average with more than two (2.62) healthcare providers contracted with the public payer. This was the 1st highest result countrywide (Figure 184).

178 Figure 184: Number of contracts with healthcare providers contracted with the public payer per one oncological gynecologist in individual voivodeships in 2012

Average number of contracts per 1 physician

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and the NFZ

In 2012, most oncological gynecologists in Mazowieckie Voivodeship were in the 40-45 age range. The median age for the Voivodeship was 45 years and it was lower by four years than the Polish one (Figure 185 and Figure 186).

Figure 185: Age structure of gynecologic oncologists in Poland in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

179 Figure 186: Age breakdown of oncological gynecologists in Mazowieckie Voivodeship in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Paediatric oncologists and haematologists

In 2012, there were 28 paediatric oncologists and haematologists working in Mazowieckie Voivodeship registered in the NIL database42. They represented approx. 6% of all paediatric oncologists and haematologists working in Poland. This was the 6th highest value countrywide (Figure 187).

Figure 187: Number of paediatric oncologists and haematologists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

42 The number of physicians is not an unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation; if the doctor has several specialisations, he is taken into account in each of them.

180 In Mazowieckie Voivodeship, in 2012, the number of paediatric oncologists and haematologists per 100,000 minors was 2.68. This was the 5th highest value countrywide (Figure 183). Figure 188).

Figure 188: Number of paediatric oncologists and haematologists per 100,000 minors

in individual voivodeships in 2012

yearsof age Number of physicians per 100,000 people below 18 below peopleNumber physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

In 2012, a paediatric oncologist and haematologist in Mazowieckie Voivodeship had a contract signed with more than two (2.71) healthcare providers contracted with the public payer. This was the 1st highest result countrywide. Figure 189).

181 Figure 189: Number of contracts with healthcare providers contracted with the public payer per one paediatric oncologist and haematologist in individual voivodeships in 2012

Average number of contracts per 1 physician

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and the NFZ

In 2012, 7 paediatric oncologists and haematologists in Mazowieckie Voivodeship were in the 50-55 age range. The median age for the Voivodeship was 50 years and it was equal to the Polish one. (Figure 190 and Figure 181).

Figure 190: Age breakdown of paediatric oncologists and haematologists in Poland in

2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

182 Figure 191: Age breakdown of paediatric oncologists and haematologists in

Mazowieckie Voivodeship in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Clinical oncologists

In 2012, there were 213 clinical oncologists working in Mazowieckie Voivodeship registered in the NIL database43. They represented approx. 25% of all clinical oncologists working in Poland. This was the 1st highest value countrywide (Figure 192).

Figure 192: Number of clinical oncologists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

In Mazowieckie Voivodeship, in 2012, the number of oncology specialists per 100,000 adults was 5.00. This was the 1st highest value countrywide (Figure 193).

43 The number of physicians is not an unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation, if the doctor has several specialisations, he is taken into account in each of them.

183 Figure 193: Number of clinical oncologists per 100,000 adults in individual voivodeships

in 2012

people over 18 years of age people18 of over years Number physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

In 2012, a clinical oncology specialist in Mazowieckie Voivodeship had a contract signed with more than two (2.41) healthcare providers contracted with the public payer. This was the 4th highest result countrywide (Figure 194).

Figure 194: Number of contracts with healthcare providers contracted with the public payer per one clinical oncology specialist in individual voivodeships in 2012

Average number of contracts per 1 physician

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and the NFZ

184 In 2012, 46 clinical oncology specialists in Mazowieckie Voivodeship were in the 45-50 age range. The median age for the Voivodeship was 42 years and it was lower by one year than the Polish one (Figure 203 and Figure 204).

Figure 195: Age structure of clinical oncologists in Poland in 2012

physicians Number of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 196: Age breakdown of clinical oncology specialists in Mazowieckie Voivodeship

in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Pathomorphologists

In 2012, there were 9 pathomorphologists working in Mazowieckie Voivodeship registered in the NIL database. They represented approx. 11% of all pathomorphologists working in Poland. This was the 3rd highest value countrywide (Figure 183).44(Figure 197 and Figure 199).

44 The number of physicians is not a unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation; if the doctor has several specialisations, he is taken into account in each of them.

185 Figure 197: Number of pathologists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 198: Number of pathologists per 100,000 adults in individual voivodeships in

2012

people18of years age below Number physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

186 Radiation therapists

In 2012, there were 65 radiation therapists working in Mazowieckie Voivodeship registered in the NIL database.45 They represented approx. 11% of all radiation therapists working in Poland. This was the 2nd highest value countrywide (Figure 200).

Figure 199: Number of radiation therapists in individual voivodeships in 2012

Number of physicians

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

In Mazowieckie Voivodeship, in 2012, the number of radiation therapists per 100,000 adults was 1.52. This was the 12th highest value countrywide (Figure 183). Figure 201).

45 The number of physicians is not a unique number: if a physician works in several voivodeships, they are taken into account in each of them. The same applies in the case of specialisation; if the doctor has several specialisations, he is taken into account in each of them.

187 Figure 200: Number of radiation therapists per 100,000 adults in individual voivodeships

in 2012

people18of years age below Number physicians100,000 per of

difference versus rate value for the country

higher value in Poland higher value in the voivodeship Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

In 2012, a radiation therapists in Mazowieckie Voivodeship had a contract signed on average with more than two (2.47) healthcare providers contracted with the public payer. This was the 2nd highest result countrywide (Figure 202).

Figure 201: Number of contracts with healthcare providers contracted with the public payer per one radiation therapists in individual voivodeships in 2012

Average number of contracts per 1 physician

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and the NFZ

188

In 2012, 45-49 and 50-54 age ranges comprised each 13 radiation therapists in Mazowieckie Voivodeship. The median age for the Voivodeship was 50 years and it was higher by five years than the Polish median (Figure 203 and Figure 204).

Figure 202: Age breakdown of radiation therapists in Poland in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 203: Age breakdown of radiation therapists in Mazowieckie Voivodeship in 2012

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Oncology nurses

In 2015, there were 1,251 oncology nurses in Poland, 86 of which were registered in Mazowieckie Voivodeship. This region ranked 14th in Poland in terms of the number of nurses per 100,000 adults.46(Figure 205 and Figure 206).

46 Nurses with the title of specialist in oncology nursing/cardiology nursing may work in a ward with a different profile than their field of specialisation. In addition, in wards with an oncological/cardiological profile, apart from nurses with the specialist title in oncology nursing and cardiology nursing, nurses also work without additional qualifications acquired as part of postgraduate education. Therefore, the numbers presented in the graph (number of nurses with the specialist title in oncology nursing/cardiology nursing) should not be interpreted as the actual number of nurses employed in the given field.

189 Figure 204: Number of oncology nurses in individual voivodeships in 2012

Number of nurses

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 205: Number of oncology nurses per 100,000 adults in individual voivodeships

in 2012

people18of years age below Number physicians100,000 per of

difference versus rate value for the country higher value in Poland higher value in the voivodeship

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber and Central Statistical Office

Similarly to Poland as a whole, in Mazowieckie Voivodeship, in 2015, most oncology nurses were between 40 and 44 years old (Figure 207 and Figure 208).

190

Figure 206: Age structure of oncology nurses in Poland in 2015

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

Figure 207: Age breakdown of oncology nurses in Mazowieckie Voivodeship in 2015

Number physicians of

Source: compiled by DAiS based on data provided by the Supreme Medical Chamber

191 CATCHING GAPS WITH HEALTHCARE MAPS CARDIOLOGY AND ONCOLOGY

Part III Healthcare Needs Forecasts

192 3.1 Projected Population Breakdown

According to the latest demographic forecast, by 2029 the population of Mazowieckie Voivodeship will have increased by 84 thousand, i.e. by 1.6%, while the Polish population will have decreased in the same period by 1.17 million people (i.e. by 3%). Figure 209).

Figure 208: Population in voivodeships in 2018, 2024 and 2029

Millions

Overall share of the population

Source: compiled based on data provided by the Central Statistical Office

The demographic structure of Mazovian population in the next several years will be changing in a similar way to the population structure in Poland in general. It is expected that the share of population below 20 years of age as well as at the age of 45-64 will slightly change. These shares were about 21% and 26% in 2014, respectively, and will be 19% and 29% in 2029. Significant changes, however, will be noticeable among people aged 20-44 and above 64. (Figure 209 and Figure 210). According to the demographic forecast, there will be a significant drop in a share of population aged 20-44 (from 38% to 30% in 2029) as well as a considerable increase in a share of people above 64 years of age: from 16% to 22% within the considered period (Figure 19 and Figure 20). In 2014, in Mazowieckie Voivodeship, there were 670 people of non-working age per every 1,000 people of working age47. In 2020, this figure will increase to 679 people and to 691 in 2029, which indicates an increasing burden on people of working age by people of non-working age. The indicator above includes changes due to the raising of

47 It was assumed that people of non-working age are aged 0-19 and of retirement age.

193 the statutory retirement age. Without the reform implemented, the values for 2020 and 2029 would amount to 755 and 772 people, respectively.

Figure 209: Projected population breakdown according to sex and age in 2029 for Mazowieckie Voivodeship

Men (in thousands) Age group Women (in thousands)

Surplus of men over women (in thousands) Surplus of women over men (in thousands)

Source: compiled based on data provided by the Central Statistical Office

194

Figure 210: Projected population breakdown by basic age groups in Poland and Mazowieckie Voivodeship in years 2016-2029

Poland Mazowieckie Voivodeship

Source: compiled based on data provided by the Central Statistical Office

195 Figure 211: Projected population breakdown by age groups in Mazowieckie Voivodeship in selected years of prognosis (2016, 2018, 2024 and 2029)

difference in relation to Poland’s population structure

higher value in Poland higher value in the voivodeship

Source: compiled based on data provided by the Central Statistical Office

Figure 212: Projected population breakdown by sex and age in Mazowieckie Voivodeship (a share and a number of people in thousands) in selected years of prognosis (2016, 2018, 2024 and 2029)

Source: compiled based on data provided by the Central Statistical Office

196 In 2014, the fertility rate in Mazowieckie Voivodeship amounted to over 44 live births per thousand women of childbearing age, while according to the demographic forecast, in Mazowieckie Voivodeship it is to be expected to decline to the level of almost 38 in 2029. Also, it is projected that approx. 12.6 thousand children less will be born, which means a decrease from 57.1 thousand children in 2014 to 44.5 thousand children in 2029. Given the forecast, Mazowieckie Voivodeship will change its position compared to other voivodeships in terms of fertility rate to rank third (Figure 214).

Figure 213: Projected fertility rate and live births in Polish voivodeships in 2029

thousands births per one thousand women aged 15 aged birthswomen one per thousand

difference versus average value for Poland:

higher value in Poland number of births (right axis)

higher value in the voivodeship

Source: compiled based on data provided by the Central Statistical Office

197 Figure 214: Projected number of deaths (in thousands) by voivodeships in selected

years of prognosis (2016, 2018, 2024 and 2029)

Projected number ofProjected(in deaths number thousands)

Source: compiled based on data provided by the Central Statistical Office

Figure 215: Projected death rates (per 100 thousand people) by voivodeships in selected

years of prognosis (2016, 2018, 2024 and 2029)

Death rate (per 100 thousandDeathpeople) (per 100 rate

Source: compiled based on data provided by the Central Statistical Office

198

3.2 Projected demographics of counties (poviats)

According to the demographic prognosis, by 2029 the number of inhabitants in some Mazovian counties will have decreased,while in other will have increased (Figure 217). The largest decrease in the population number should be expected in the following counties: Lipsko (by 12%), Sokołów Podlaski, Przysucha (by 10%), Radom City, Płock City, Żuromin, Ostrołęka City (by 9%), Maków Mazowiecki, Łosice, Ostrów Mazowiecka (by 8%). Whereas the population of the following counties will increase: Piaseczno (by 20%), Wołomin (by 18%), Grodzisk Mazowiecki (by 15%), Legionowo (by 16%), Ożarów Mazowiecki (by 13%), Pruszków (by 9%), Mińsk Mazowiecki (by 8%), Otwock (by 6%).

Figure 216: Population in counties of Mazowieckie Voivodeship in selected years of

prognosis (2018, 2024 and 2029)

population number (in thousands) populationnumber(in

share of the total population (right axis) Source: compiled based on data provided by the Central Statistical Office

Over the considered prognostic period, the changes in the demographic structure of population in Mazovian counties will occur in a similar way to the entire voivodeship. It is expected that the share of people aged 20 and 45-64 will be relatively constant, while there will be a significant drop in the share of individuals at the age 20-44 in favour of individuals above 65, as in the demographic forecast. By 2029, major changes in shares of particular age groups should be expected in city counties, as well as e.g. in the counties of Ciechanów, Gostynin and Lipsko (Figure 218).

199 By 2029, the highest share of people above 65 years of age will have been observed in: Lipsko County (26.8%), Płock City (26.5%), Radom City (26.4%), Gostynin County and Sokołów Podlaski County (25.2%). The lowest number of individuals older than 65 in 2029 will have occurred in the following counties: Wołomin (17.8%), Piaseczno (18.1%) and Ostrołęka (18.5%) (see Figure 218). Figure 219 shows the projected demographic situation in counties with sex and age group breakdown.

200 Figure 217: Projected population breakdown by age in counties of Mazowieckie Voivodeship in selected years of prognosis (2016, 2018, 2024 and 2029)

county białobrzeski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county ciechanowski

differencedifference versus versus the the structure structure of of the the voivodeship: voivodeship:

higherhigher share share in in the the county county higherhigher share share in in the the voivodeship voivodeship

county garwoliński

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

201 county gostyniński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county grodziski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county grójecki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

202 county kozienicki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county legionowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county lipski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

203 countyłosicki

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county makowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county miński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

204 county mławski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county nowodworski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county ostrołęcki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

205 county ostrowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county otwocki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county piaseczyński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

206 county płocki

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county płoński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county pruszkowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

207 county przasnyski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county przysuski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county pułtuski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

208 county radomski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county siedlecki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county sierpecki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

209 county sochaczewski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county sokołowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county szydłowiecki

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

210 county warszawski zachodni

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county węgrowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county wołomiński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

211 county wyszkowski

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county zwoleński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county żuromiński

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

212 county żyrardowski

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

country. Ostrołęka

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

county c. Płock

difference versus the structure of the voivodeship: higher share in the county higher share in the voivodeship

213 County m. Radom

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county c. Siedlce

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship

county c. Warsaw

difference versus the structure of the voivodeship:

higher share in the county higher share in the voivodeship Source: compiled based on data provided by the Central Statistical Office

214 Figure 218: Projected population breakdown by sex in counties of Mazowieckie Voivodeship in selected years of prognosis (2016, 2018, 2024 and 2029)

county bialobrzeski

county grodziski

county ciechanowski

county grójecki ```

215 county kozienicki

county garwoliński

county legionowski

county gostyński

county lipski

216 county łosicki county ostrołęcki

county makowski county ostrowski

county miński county otwocki

county mławski county piaseczyński

county nowodworski county płocki

217 county płoński county radomski

county pruszkowski county siedlecki

county przasnyski county sierpecki

county przysuski county sochaczewski

county pułtuski county sokołowski

218 county szydłowiecki county zwoleński

county warszawski zachodni county żuromiński

county węgrowski county żyradowski

county wołomiński county. Ostrołęka

county wyszkowski county Płock

219 county Radom

county. Siedlce

county Warsaw

Source: compiled based on data provided by the Central Statistical Office

Over the considered period of prognosis, the fertility rate in Mazowieckie Voivodeship will decrease to 38 live births per one thousand women of childbearing age (Figure 220). In 2029, the highest rate will be characteristic of the following counties: Garwolin, Siedlce, Węgrów, Mińsk Mazowiecki, Łosice, Ostrołęka, Wyszków and Przasnysz, while the lowest of Warsaw- West, Capital City of Warsaw, Radom City and Lipsko County. (cf. Figure 220).

220

Figure 219: Forecast fertility rate and live births in Mazovian counties (poviats) in 2029

thousands births per one thousand women aged 15 aged birthswomen one per thousand

difference versus average value for Mazowieckie Voivodeship higher average value in the voivodeship number of births (right axis) higher value in the county

Source: compiled based on data provided by the Central Statistical Office

The observed number of deaths in a given population is a resultant of its size, health condition and age structure. Therefore, comparing the number of deaths is inadvisable, while comparing general (raw) death rates between different regions ought to be taken with great caution. Figure 221 and Figure 222 show the number of deaths and raw death rate for selected years of prognosis (2016, 2018, 2024 and 2029). In the analysed Voivodeship, the majority of counties will experience a rise (smaller or larger) in the death rates which is related to the population ageing. The highest death rate is projected for Lipsko, Sokołów Podlaski, Przysucha i Łosice counties. On the other hand, the lowest values for this rate will be observed in Wołomin, Piaseczno and Legionowo counties.

221 Figure 220: Projected number of deaths (in thousands) by counties of Mazowieckie

Voivodeship in selected years of prognosis (2016, 2018, 2024 and 2029)

Projected number ofProjected deaths number

Source: compiled based on data provided by the Central Statistical Office

Figure 221: Death rates (per 100 thousand people) by counties of Mazowieckie

Voivodeship in selected years of prognosis (2016, 2018, 2024 and 2029)

Projected100,000 people per deaths

Source: compiled based on data provided by the Central Statistical Office

222 3.3 Epidemiology Forecast

3.3.1 Incidence Forecast

Figure 222: Projected number of new cancer cases in Poland in thousands in the years

2016-2029

Projected number of new cases in of new number thousands Projected

YEAR Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 224: Projected number of new cancer cases in Poland in 2029 by voivodeship

Projected new cases in 2029 (in thousands)

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 225: The projected change in the number of new cancer cases in Poland by voivodeship in 2029 versus 2016. In the years 2016-2029, a continued increase in the number of new cancer cases in Poland is expected (Figure 223). In 2016, the number of new cases will amount

223 to 180.29 thousand, and by 2029, they will reach 213.14 thousand. This means an increase of 18% over 14 years.

Figure 223: Projected number of new cancer cases in Poland in 2016 by voivodeship

Projected new cases in 2016 (in thousands)

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, the highest number of new cancer cases in Poland will be recorded in Mazowieckie Voivodeship (25.1 thousand) (Figure 224). In one half of voivodeships, the number of new cases will exceed 9.9 thousand. Lubuskie Voivodeship will have the lowest number (4.7) of new cases.

224 In 2029, the highest number of new cancer cases in Poland will again be recorded in Mazowieckie Voivodeship (30 thousand) (Figure 225). Less than 11.7 thousand of new cases will be recorded in one half of the voivodeships, the least in Opolskie Voivodeship (5.6 thousand).

The change in the number of new cancer cases differed in size between voivodeships (Figure 226). The most substantial increase will be recorded in Pomorskie and Wielkopolskie Voivodeships (23% in each), whereas it will be the least marked in Łódzkie (11.6%) and Śląskie (13.4%) Voivodeships. In Mazowieckie Voivodeship, the increase in the number of new cancer cases between 2029 and 2016 will amount to 19.7%.

Figure 226: Projected number of new cases in Poland in 2029 by cancer groups

Lungs Breast Prostate Colon Bladder Upper gastrointestinal tract Anus and rectum Corpus uteri Kidney Pancreas Cervix Melanoma CNS Oral cavity Larynx Thyroid Gallbladder Liver Oesophagus Nasal cavity and sinuses Testis Lip Salivary gland

Projected number of new cases in thousands in Poland in 2029 by cancer group

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry,

the NFZ and the Main Statistical Office

Figure 227: Changes in the number of new cases in percentages between 2016 and 2029 by cancer

Prostate Lip Gallbladder Colon Bladder Upper gastrointestinal tract Anus and rectum Pancreas Liver Lungs Salivary gland Corpus uteri Oesophagus Melanoma Ovary Breast Larynx Nasal cavity and sinuses CNS Cervix Oral cavity Thyroid Testis

Changes in the number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

225 In 2029, most new cancer cases reported in Poland will be that of the lung (over 32,000) (Figure 227). Breast cancer is to rank second at almost 23,000 new cases. In 2029, cancer of the salivary gland and lip will be the least reported ones in Poland. The number of new cases of this cancer will amount to 766 and 817, respectively.

The most substantial change in the incidence of cancers is observed in prostate cancer (Figure 228). In 2029, the number of new cases will be by 29% higher compared to 2016. This is due to high incidence rate of this type of cancer in 65+ people and to the ageing of the society, i.e. the increasing rate of the number of people over 65 to those under 65. The second highest increase will occur in the number of new lip cancer cases (28%). The reasons for this are similar to those behind prostate cancer, however, lip cancer is one of the less frequent cancers in Poland.

Particular attention should be paid to other, most common types of cancers present in Poland, i.e. lung, breast and large intestine cancers. In 2029, compared to 2016, the number of new lung cancer cases will be 17% higher, the number of new breast cancer cases will be 13% higher, and that of colorectal cancer 23% higher.

The only type of cancer with the number of new cases in 2029 to be smaller than that recorded in 2016 will be testicular cancer. This is due to the fact that the highest incidence of this type of cancer is observed in the 0-44 age group, whose share in the Polish population will decrease.

Figure 228: Changes in the number of new cases in percentages between 2016 and 2029 by age group

Changes in patients’ age structure between 2016 and 2029

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

The major change in the incidence of cancers will be observed in 75-84-year-old patients (Figure 229). A 60% increase on 2016 in new cases is projected for 2029. Also in the 65-74

226 and 85+ age groups, an increase in the number of new cancer cases of 27% and 21%, respectively, is to be observed. This is mainly due to the ageing of the society, i.e. the increasing rate of the number of people over 65 to those under 65. Accordingly, a decrease in the number of new cancer cases in the 0-44 and 55-64 age groups will be observed, by 18% and 16%, respectively. Note that the number of new cancer cases in 2029 in the 45-54 age group will be by 29% higher in 2029 compared to 2016. This is the due to a high incidence of the most common cancers, i.e. those of the breast, lungs and large intestine, among this age group.

Malignant neoplasms of trachea, bronchus and lung (C33, C34)

Figure 229: Projected number of new lung cancer cases (C33, C34) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

227

Figure 230: Projected number of new lung cancer cases (C33, C34) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 231: Projected change in number of new lung cancer cases (C33, C34) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are over 27.6 thousand new cases of cancers of the trachea, bronchus and lungs (hereinafter: lungs) projected in Poland (Figure 230). Most of them will occur in Mazowieckie (3,830) and Śląskie (3,471) Voivodeships. The distribution median of the number

228 of new cases of this group is to be 1,519, which means that the number of new cases will exceed that value in one half of voivodeships. Lubuskie Voivodeship will see the lowest number of new cases (725).

In 2029, there are over 32.5 thousand new cases of cancers of the trachea, bronchus and lungs projected in Poland (Figure 231). Again, most of them will be reported in Mazowieckie (4,548) and Śląskie (3,898) Voivodeships. In one half of the voivodeships there will be more than 1,781 new cases of cancer of this group. Opolskie Voivodeship will see the lowest number of new cases (854).

The major increase in new cases of the trachea, bronchus and lung cancer will be recorded in Podkarpackie Voivodeship (23%) (Figure 232). The median increase in the number of new cases will amount to 19%, with the lowest increase to be recorded in Łódzkie Voivodeship (10%). In Mazowieckie Voivodeship, the number of new cases of cancers of the trachea, bronchus and lungs in 2029 will be 19% higher compared to 2016.

Malignant neoplasms of the breast (C50, D05)

Figure 232: Projected number of new breast cancer cases (C50, D05) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

229

Figure 233: Projected number of new breast cancer cases (C50, D05) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 234: Projected change in the number of new breast cancer cases (C50, D05) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are over 20.3 thousand new cases of breast cancers projected in Poland (Figure 233). There will be most of the in Mazowieckie Voivodeship (2,803), and in one half of

230 voivodeships the number of new cases will exceed 1,117. The lowest incidence of breast cancers will be observed in Lubuskie Voivodeship (535).

In 2029, there are over 22.9 thousand new cases of breast cancers projected in Poland (Figure 234). Most of them will again be reported in Mazowieckie Voivodeship (3,205). The distribution median of the number of new cases of this group is to be 1,254, which means that this number will exceed that value in one half of voivodeships. Opolskie Voivodeship will have the lowest number (592) of new cases.

The major increase in the incidence of new breast cancers will be recorded in Małopolskie, Pomorskie and Wielkopolskie Voivodeships: 17% in each (Figure 235). The median increase in the number of new cases will amount to 13%, with the lowest increase to be recorded in Łódzkie Voivodeship (7%). In Mazowieckie Voivodeship, the number of new cases of breast cancer in 2029 will be 16% higher compared to 2016.

Malignant neoplasms of colon and rectosigmoid junction (C18, C19)

Figure 235: Projected number of new colon cancer cases (C18, C19) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

231 Figure 236: Projected number of new colon cancer cases (C18, C19) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 237: Projected change in the number of new colon cancer cases (C18, C19) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are 15.1 thousand new cases of colon cancers projected in Poland (Figure 236). Mazowieckie Voivodeship will see the highest number of new cases (2,130). The distribution median of the number of new cases of this group is to be 834, which means that the number

232 of new cases will exceed that value in one half of voivodeships. The lowest number of new cases will be reported in Lubuskie Voivodeship (390).

Over 18.7 thousand new cases of colon cancer are projected for 2029 in Poland (Figure 237), with most of these to be reported in Mazowieckie and Śląskie Voivodeships: 2,635 and 2,257, respectively. In one half of voivodeships, the number of new cases will exceed 1,024. The lowest number of new cases, 489, will be diagnosed in Opolskie Voivodeship.

The most considerable increase in the incidence of colon cancers will be recorded in Pomorskie, Warmińsko-Mazurskie and Wielkopolskie Voivodeships: 28% each (Figure 238). In one half of voivodeships, the increase in the number of new cases will exceed 24%, with the lowest increase to be recorded in Łódzkie Voivodeship (17%). In Mazowieckie Voivodeship, the number of new cases of colon cancers in 2029 will be 24% higher compared to 2016.

Malignant neoplasms of the rectum and anus (C20, C21)

Figure 238: Projected number of new rectum and anus cancer cases (C20, C21) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

233 Figure 239: Projected number of new rectum and anus cancer cases (C20, C21) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 240: Projected change in number of new rectum and anus cancer cases (C20, C21) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are over 8.6 thousand new cases of rectum and anus cancers projected in Poland (Figure 239). Most of them will occur in Mazowieckie (1,209) and Śląskie (1,087) Voivodeships. The distribution median of the number of new cases of this group is to be 476,

234 which means that the number of cases will be below that value in one half of voivodeships. Lubuskie Voivodeship will have the lowest number (224) of new cases.

In 2029, there will be over 10.5 thousand new cases of rectum and anus cancers in Poland (Figure 240). Most of them are forecast to occur in Mazowieckie (1,480) and Śląskie (1,266) Voivodeships. The distribution median of the number of new cases of this group is to be 576. Opolskie Voivodeship will have the lowest number (275) of new cases.

The major increase in the incidence of new cases of rectum and anus cancers will be recorded in Pomorskie, Warmińsko-Mazurskie and Wielkopolskie Voivodeships: 26% in each (Figure 241). The median increase in the number of new cases will amount to 22%. The increase will be smallest in Łódzkie (15%) and Śląskie (16%) Voivodeships. In Mazowieckie Voivodeship, the number of new cases of rectum and anus cancers in 2029 will be 22% higher compared to 2016.

Malignant neoplasm of prostate (C61)

Figure 241: Projected number of new prostate cancer cases (C61) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

235 Figure 242: Projected number of new prostate cancer cases (C61) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 243: Projected change in the number of new prostate cancer cases (C61) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are over 16.4 thousand new cases of prostate cancer projected in Poland (Figure 242). Most of them will occur in Mazowieckie (2,267) and Śląskie (2,074) Voivodeships. The distribution median of the number of new cases of this group is to be 893, which means

236 that the number of new cases will exceed that value in one half of voivodeships. Lubuskie Voivodeship will have the lowest number (424) of new cases.

In 2029, there are over 21.2 thousand new cases of prostate cancer projected in Poland (Figure 243), with most of them to be reported in Mazowieckie Voivodeship (2922). In one half of voivodeships, the number of new cases of this type will exceed 1,171. Opolskie Voivodeship will have the lowest number (567) of new cases.

The major increase in the incidence of new cases of prostate cancer will be recorded in Warmińsko-Mazurskie Voivodeship (37%) (Figure 244). In one half of voivodeships, the increase in the number of new cases will amount to 31% or more. The increase will be smallest in Łódzkie (22%) and Śląskie (23%) Voivodeships. The number of new cases of prostate cancer in Mazowieckie Voivodeship in 2029 will be greater by 29% compared to the situation in 2016.

Malignant neoplasm of bladder (C67)

Figure 244: Projected number of new bladder cancer cases (C67) in 2016

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

237 Figure 245: Projected number of new bladder cancer cases (C67) in 2029

Projected number of new cases

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 246: Projected change in the number of new bladder cancer cases (C67) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, there are over 9.3 thousand new cases of bladder cancer projected in Poland (Figure 245). Most of them will occur in Mazowieckie (1,312) and Śląskie (1,169) Voivodeships. The distribution median of the number of new cases of this type is to be 514, which means that the number of new cases will exceed that value in one half of voivodeships. Lubuskie Voivodeship will have the lowest number (240) of new cases.

238 Over 11.5 thousand new cases of bladder cancer are projected for 2029 in Poland (Figure 246), with most of these again to be reported in Mazowieckie and Śląskie Voivodeships: 1,620 and 1,390, respectively. More than 630 new cases will be recorded in one half of the voivodeships in Poland, with the least to be reported in Opolskie Voivodeship (301).

The most considerable increase in the new bladder cancer cases will be recorded in Pomorskie, Warmińsko-Mazurskie and Wielkopolskie Voivodeships: 28% in each (Figure 247). One half of the voivodeships will see an over 24% increase in the number of new bladder cancer cases, while in Mazowieckie Voivodeship this increase will be of the order of 23% (the lowest increase of 16% is to be recorded in Łódzkie Voivodeship).

Malignant neoplasms of the breast (C33, C34)

Figure 247: Projected number of new lung cancer cases (C33, C34) in 2016

Projected number of new cases in 2016

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

239 Figure 248: Projected number of new lung cancer cases (C33, C34) in 2029

Projected number of new cases in 2029

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 249: Projected change in number of new lung cancer cases (C33, C34) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, the fewest new lung cancer cases are projected for the counties of Białobrzegi (22), Łosice (23) and Zwoleń (25) (Figure 248). The median of infections projected for 2016 was 54, which means that in one half of the counties lower values are projected, and higher ones in

240 the other half. The largest number of new patients with lung cancer should be expected for the City of Warsaw (1,344) and the neighbouring counties, including Wołomin (144) and Pruszków (115).

It is projected that in 2029 most lung cancer cases will occur in the same counties as in 2016, with only the values for individual counties varying. Counties to have the smallest number of new cases are also recurrent. The median number of new cases for 2029 was 66, which means that less than 66 patients diagnosed with lung cancer diagnosed in 2029 are expected to live in one half of Mazovian counties. In the other half, it will be more than 66 patients.

Mazovian counties vary in terms of the structure of age groups, so that various incremental increases are to be expected depending on the county. The largest increase in the number of lung cancer cases between 2016 and 2029 is projected for the counties that surround Warsaw. These include the counties of Piaseczno (42%), Wołomin (40%) and Legionowo (35%) (Figure 250). The median increase in the incidence of lung cancer cases was 21%, which means that a larger increase is forecast for one half of the counties, and an increase of below 21% for the other half. The smallest increase in lung cancer incidence is projected for Warsaw (10%) and the county of Lipsko (11%).

Malignant neoplasms of the breast (C50, D05)

Figure 250: Projected number of new breast cancer cases (C50, D05) in 2016

Projected number of new cases in 2016

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

241 Figure 251: Projected number of new breast cancer cases (C50, D05) in 2029

Projected number of new cases in 2029

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 252: Projected change in the number of new breast cancer cases (C50, D05) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, the fewest new breast cancer cases are projected for the counties of Łosice (18, Białobrzegi (19), Zwoleń (21) and Lipsko (21) (Figure 251). The median of breast cancer cases

242 is to amount to 40 in 2016 in the Voivodeship, which means that in one half of the counties lower values were recorded, and higher ones in the other half. The largest number of new patients with breast cancer should be expected for the City of Warsaw (950) and the neighbouring counties, including Wołomin (111) and Piaseczno (86).

In 2029, the largest and the smallest number of patients were present in the same counties as in 2016. The median of prevalence projected for 2029 is 46, which means that in one half of the counties lower values are projected, and higher than 46 new breast cancer cases annually in the other half.

Mazovian counties vary in terms of the structure of age groups, so that various incremental increases are to be expected depending on the county. The largest increase in the number of breast cancer cases between 2016 and 2029 is projected for the counties that surround Warsaw. These include the counties of Piaseczno (38%) and Legionowo (34%) (Figure 253). The median increase in the incidence of breast cancer cases was 13%, which means that a larger increase is forecast for one half of the counties, and an increase of below 13% for the other half. The smallest increase in the number of cases is projected for the counties of Sokołów Podlaski (3%) and Przysucha (4%)

Malignant neoplasms of colon and rectosigmoid junction (C18, C19)

In 2016, the fewest new colon cancer cases are projected for the counties of Białobrzegi (12), Łosice (13) and Zwoleń (14) (Figure 254). The median of the number of new cases projected for 2029 is 30, which means that in one half of the counties lower values are projected, and higher than 30 new colon cancer diagnoses in the other half. The highest incidence rates are projected for the City of Warsaw (766) and the counties that surround it, such as that of Wołomin (78) and Pruszków (63).

243 Figure 253: Projected number of new colon cancer cases (C18, C19) in 2016

Projected number of new cases in 2016

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ, the BDL and the Main Statistical Office

Figure 254: Projected number of new colon cancer cases (C18, C19) in 2029

Projected number of new cases in 2029

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

244 Figure 255: Projected change in the number of new colon cancer cases (C18, C19) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2029, the largest and the smallest number of patients are to be present in the same counties as in 2016. The median of prevalence projected for 2029 is 38, which means that in one half of the counties lower values are projected, and higher than 38 new colon cancer cases annually in the other half. Figure 255).

The largest changes in new colon cancer diagnoses are projected for the counties neighbouring with the City of Warsaw. These include the counties of Wołomin (45%), Legionowo (43%) and Piaseczno (46%) (Figure 256). The median increase in the incidence of cancer cases was 26%, which means that an increase larger than 26% is forecast for one half of the counties, and a smaller increase for the other half. The smallest increase in the number of new diagnoses is projected for the counties of Przysucha (11%) and Żuromin (12%)

245 Malignant neoplasm of prostate (C61)

Figure 256: Projected number of new prostate cancer cases (C61) in 2016

Projected number of new cases in 2016

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 257: Projected number of new prostate cancer cases (C61) in 2029

Projected number of new cases in 2029

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

246 Figure 258: Projected change in the number of new prostate cancer cases (C61) in 2029 compared to 2016

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

In 2016, the fewest new prostate cancer cases are projected for the counties of Białobrzegi (13), Zwoleń (15) and Łosice (15) (Figure 257). The median of the value projected for 2016 is 32, which means that in one half of the counties lower values are projected, and higher ones in the other half. The highest rates are projected for the City of Warsaw (793) and the counties that surround it, such as that of Wołomin (83) and Pruszków (68).

In 2029, the largest and the smallest number of patients are to be present in the same counties as in 2016. The median of prevalence projected for 2029 is 44, which means that in one half of the counties lower values are projected, and higher than 44 new prostate cancer cases annually in the other half. Figure 258).

The largest increase in new prostate cancer diagnoses are projected for the counties neighbouring with the City of Warsaw. These include the counties of Wołomin (52%), Piaseczno (50%) and Nowy Dwór Mazowiecki (44%) (Figure 259). The median increase was 38%, which means that a larger increase is forecast for one half of the counties, and an increase of below 38% for the other half. The smallest increments of new diagnoses, but at a still high double-digit level are projected for the City of Warsaw (15%). It should be noted that according to forecasts 3/4 of the increment increase values will be higher than 31%.

247 3.3.2 5-Year Prevalence Forecast

The term "incidence" refers to newly diagnosed patients, i.e. people who appear in the system in a given year for the first time with a given cancer diagnosis. However, in terms of healthcare needs, a further stage of treatment is also of importance. Therefore, in terms of epidemiology, it is important to determine the incidence rate of cancers, but also the prevalence, relating to the number of people with a disease in a given year. Given the specificity of cancer diseases, 5-year prevalence was determined, i.e. the number of surviving patients diagnosed with a cancer in the last 5 years. The prevalence forecast, just as the incidence forecast, assumes fixed incidence and survival rates. The change affecting the forecast is the demographic forecast from the database of the Central Statistical Office.

Figure 260 shows a 5-year incidence forecast for the years 2016-2029 In 2016, it will amount to over 472,000 patients, and in 2029 – to nearly 555,000, assuming no change in the survival rate of cancer patients and the incidence of cancers – within 14 years there will be a 17% increase in prevalence. This means that in 2016, 16 out of 1,000 people will live with a cancer disease diagnosed in the last 5 years. In 2029, this figure is to amount to no less than 17 per 1,000 people. The increase in cancer prevalence over the years to come is due to the level of treatment, the process of ageing of the population, and the fact that cancer diseases mainly involve older age groups.

Figure 259: Projected 5-year cancer prevalence in thousands (2016-2029)

year prevalencein thousands year

- 5

Year

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

5-year prevalence in particular voivodeships is similar to incidence, i.e. in 2016, the highest values are to be expected in Mazowieckie, Śląskie, Wielkopolskie and Małopolskie Voivodeships (Figure 261). It will amount to 64 thousand, 56 thousand, 39 thousand and 37 thousand, respectively. Prevalence rate closely correlates with the number of population, also as regards the projected values, and this relationship is going to continue in 2029 (Figure 262).

248 Mazowieckie Voivodeship will continue to have the highest prevalence rate – at 78,000. In Śląskie, Wielkopolskie and Małopolskie Voivodeships it will amount to 67 thousand, 49 thousand and 48 thousand, respectively.

Figure 260: Projected 5-year cancer prevalence in 2016

Projected 5-year prevalence (in thousands)

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 261: Projected 5-year cancer prevalence in 2029

Projected 5-year prevalence (in thousands)

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

249 The increase in prevalence, however, will vary between voivodeships. The years 2016-2029 will probably see the highest increase in prevalence, mainly in south-eastern Polish voivodeships (Figure 263). The highest increase is to be recorded in Podkarpackie (27%), Opolskie (27%), but also in Małopolskie (22%) and Lubelskie (21%) Voivodeships. Łódzkie (10%), Śląskie (12%) and Świętokrzyskie (13%) Voivodeships will have the lowest increase in prevalence in 2016-2029. The median of the percentage increase in prevalence is 17%, which means that in one half of the voivodeships in Poland prevalence will increase by more than 17% in 14 years.

Figure 262: Projected increase (%) in 5-year prevalence in the years 2016-2029

Projected change

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

To sum up, a prevalence rate of over 450,000 is to be expected in 2016, which means that there will be over 450,000 living people in Poland to have been diagnosed with cancer in the last five years. This number will grow in the years to come and it will vary in size between voivodeships. The highest increase in 5-year cancer prevalence should be expected in Podkarpackie, Opolskie, Małopolskie and Lubelskie Voivodeships, which is mainly due to the more dynamic process of population ageing in these Voivodeships.

250 Figure 263: Projected changes in 5-year prevalence in Mazowieckie Voivodeship between 2016 and 2029 (part 1)

Breast Prostate Colon Corpus uteri Lungs Bladder Kidney Anus and rectum Melanoma Ovary Cervix Thyroid

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry, the NFZ and the Main Statistical Office

Figure 264: Projected changes in 5-year prevalence in Mazowieckie Voivodeship between 2016 and 2029 (part 2)

Upper gastrointestinal tract Larynx CNS Oral cavity Testis Pancreas Nasal cavity and sinuses Liver Lip Gallbladder Salivary gland Oesophagus

Source: compiled by DAiS based on data provided by the Polish National Cancer Registry,

the NFZ and the Main Statistical Office

The highest 5-year prevalence in Mazowieckie Voivodeship in 2016 will relate to breast cancers to amount to 11,887, i.e. according to the forecast in 2016 there will be 11.8 thousand people living who had been diagnosed with a breast cancer in the years 2012-2016. Figure 264). Another type of cancer with the second highest 5-year prevalence will be prostate cancer (9,359). The same two cancer groups will have the highest prevalence in 2029: 12,801 for breast cancer and 10,933 for prostate cancer.

Cancers of the oesophagus and salivary gland are those with the lowest 5-year prevalence in Mazowieckie Voivodeship in 2016, amounting to 224 and 304, respectively (Figure 265). In 2029, cancers of salivary gland (311) and oesophagus (234) will have the lowest prevalence.

251 The largest increase in 5-year prevalence in Mazowieckie Voivodeship in the described years will occur in cancers of the lip, rectum and anus and of the upper gastrointestinal tract. These cancers will see an increase in 5-years prevalence of 22.9%, 20.6% and 20.2%, respectively in 2016. The smallest increase in prevalence is to involve cancers of the thyroid (0.9%) and salivary gland (2.3%).

3.4 Services Forecast

3.4.1 Surgery Services Forecast

On January 1, the so-called oncology package became effective, designed mainly to provide patients with diagnosed cancer with access to fast diagnostics and comprehensive high-quality treatment. In the long-term, the oncology package is to result in increased survival rates of patients diagnosed with cancer by the disease being detected at an early stage, coordinating the fast treatment process, and reducing the costs of treating cancer patients by detecting the disease at an early stage. The cancer treatment process actively involves primary healthcare providers, where cancer-targeted alertness is promoted, through outpatient specialist care, where the patient is quickly diagnosed, to hospitals where the patient receives comprehensive high-quality care based on the treatment plan prepared by an interdisciplinary team of specialists.

The basic document to ensure the viability of the oncology package is the oncology diagnostics and treatment card (the DILO card), designed to make it easier for the patient with a suspected or diagnosed cancer disease to move in the new healthcare system. There is no billing limit for the services related to cancer diagnostics and treatment as part of the oncology diagnostics and treatment card. This will allow an easier and faster access to treatment to cancer patients. The limits have been abolished in health care facilities that provide services under the oncology package (they ensure timeliness, comprehensiveness and quality of services). Under the hospital treatment, healthcare services are settled on a non-limit basis within the scope of combined treatment – oncology package. Accordingly, the forecast of the number of contracts in the further part of this study relates to said combined treatment.

Based on NFZ reports for 2009–2014, an empirical model of hospitalisation with the purpose of performing a radical surgical procedure was developed. According to the data, for each patient cohort, the number and timing of procedures were identified, and divided by: cancer type (as per cancer groups), stage at the time of diagnosis, age groups and the voivodeship where the patient received treatment.

Each cohort had its 5-year treatment pathway established using the newest available data (for the 4th and 5th year of treatment the information was extended with the treatment methods in

252 patients from previous cohorts, i.e. patients diagnosed in 2011 and 2010, respectively). The specificity of the surgical treatment (to be implemented as soon as possible after diagnosis) is such that the errors resulting from the supplementation for the 4th and 5th year of treatment are only minor48. Surgical procedures performed in patients reported in the NFZ system with suspected cancer diagnosis have also been taken into account. The condition for the inclusion of such surgery in the model was the fact that a patient with a cancer diagnosis reappeared in the healthcare system within six months from the surgery.

Each cohort had its 5-year treatment pathway established using the newest available data (for the 4th and 5th year of treatment the information was extended with the treatment methods in patients from previous cohorts, i.e. patients diagnosed in 2011 and 2010, respectively). The specificity of the surgical treatment (to be implemented as soon as possible after diagnosis) is such that the errors resulting from the supplementation for the 4th and 5th year of treatment are only minor49. Surgical procedures performed in patients reported in the NFZ system with suspected cancer diagnosis have also been taken into account. The condition for the inclusion of such surgery in the model was the fact that a patient with a cancer diagnosis reappeared in the healthcare system within six months from the surgery.

The projected demand for hospitalisations in order to perform a radical surgery was established based on the empirical model of treatment, as well as on the previously presented incidence forecast for years 2016, 2018, 2024, 2029. It was assumed that patients diagnosed in a given voivodeship will be treated therein; the model defines the needs of residents of a given voivodeship, and in its basic version, it does not take migration into consideration. Table 27 shows the demand for hospitalisations with the performance of a surgical procedure in the most common cancer groups in the Voivodeship.

Table 27: Projected demand for hospitalisations with the purpose of performing a surgical procedure in the most common cancer groups in Mazowieckie Voivodeship

2016 2018 2024 2029

lower gastrointestinal tract cancer 2,002 2,067 2,287 2,464

48 Due to the small number of cases in some groups, supplementation was performed based on information averaged for cohorts defined by cancer and stage, without taking the patient's voivodeship of origin or age group into account. 49 Due to the small number of cases in some groups, supplementation was performed based on information averaged for cohorts defined by cancer and stage, without taking the patient's voivodeship of origin or age group into account.

253 gynaecological cancer 1,562 1,601 1,718 1,801

kidney cancer 920 947 1,025 1,081

breast cancer 2,533 2,584 2,762 2,916

lung cancer 772 798 851 874 Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

Since contracting of services is classified into scopes of treatment, it was necessary to distribute the findings accordingly. For this purpose, the information on the structure of the currently performed hospitalisations according by scopes was superposed onto the forecast above. This served as a basis to estimate the distribution of procedures in individual scopes. In the next step, assuming that large centres (i.e. those that meet the criterion of 60 procedures per year) maintain the current number of procedures, the maximum number of contracts for particular scopes dedicated to cancer patients was defined (i.e. unlimited combined treatment – oncology package). Table 28 shows the scopes in which the number of contracts in the scopes dedicated to the oncology package is lower than that of the currently performed ones. Values in parentheses mean that this value is not lower than the current number of those performing unlimited combined treatment – oncology package, but it has been included for clarity.

Figure 265: Projected demand for hospitalisations with the purpose of performing a radical surgical procedure in the most common cancer groups in Mazowieckie Voivodeship

lower gastrointestinal tract cancer gynaecological cancer kidney cancer breast cancer lung cancer Other Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

The performed analysis (based on the demographic changes only, ceteris paribus) indicates that the demand for hospitalisation for the purpose of performing radical surgical procedures will increase from 11.4 thousand in 2016 to 13.3 thousand in 2029 (+16%)(Figure 266).

254 Table 28: The maximum number of contracts for the provision of "oncology package" combined treatment enabling the performance of at least 60 surgical procedures annually for each cancer group

Oncology package – unlimited combined treatment 2016 2018 2024

GENERAL SURGERY 36 38 41

MAXILLO-FACIAL SURGERY 1 1 1

NEUROSURGERY 4 4 4

OTOLARYNGOLOGY 7 7 7

OBSTETRICS AND GYNAECOLOGY 17 17 19 Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

In 2016, the maximum number of contracts for the provision of "oncology package" combined treatment should somewhat decrease compared to the year 2015 and should not exceed: 36 – general surgery – oncology package combined treatment, 1 – maxillofacial surgery – oncology package combined treatment, 4 – neurosurgery – oncology package combined treatment, 7 – otorhinolaryngology – oncology package combined treatment, 17 – obstetrics and gynaecology – oncology package combined treatment. The above numbers result from the need to centralise the radical surgical treatment, which is vital to ensure the proper level of patient's safety.

3.4.2 Positron Emission Tomography Treatment Forecast

Due to the strengthening position of PET diagnostics (including an increase in the number of scans from 29,346 in 2012 to 34,174 in 2014), the forecasts used the implementation level for 2014. Based on the actual performance level, the number of scans performed in individual patient groups defined by the patient’s voivodeship of residence,50 age (by age groups) and gender. Based on these data, the implementation rates for these services were developed. Combining this with the forecast by the Central Statistical Office for the years 2016, 2018, 2024 and 2029 produces a forecast of demand for PET scans at the level of almost 5.6 thousand in 2016 to almost 6.4 thousand in 2029 (cf. Table 2951) forecast taking into account the changes in the demographic structure). Projected equipment demand was presented in two scenarios:

50 If the patient’s TERYT code was not reported (TERYT code was not assigned to the patient in the Central Registry of Insured Persons), TERYT code of the service provider was assigned (assuming the patient has not migrated). 51 The implementation presented relates to the provision of services in the Voivodeship, i.e. it refers to the potential in a given voivodeship.

255 implementation at the level of 1,913 scans per device (an average number in 201452) and 4,474 scans per device (the highest number reported in 2014)53.

Table 29: Forecast of demand for PET scans for the inhabitants of Mazowieckie Voivodeship

Required equipment Year Projected number of Projected number of treatments patients 1913/1 4474/1

2016 5,591 5,027 3 2

2018 5,728 5,158 3 2

2024 6104 5,520 4 2

2029 6,360 5,767 4 2

Implementation in 2014 6,875 6,150 2 Source: compiled based on data provided by the NFZ

Based on the forecast, it can be concluded that the current potential (and implementation) in the voivodeship is sufficient to meet the needs of its inhabitants. However, due to the importance of the voivodeship as a migration destination of patients from other voivodeships, a development of the equipment base, if any, should be coordinated with Lubelskie, Podlaskie and Łódzkie Voivodeships (in 2014: 382, 486 ad 180 services respectively, i.e. a decrease compared to 2012).

3.4.3 Chemotherapy Services Forecast

Based on the data available, the number of chemotherapy services was projected for 2016, 2018, 2024 and 2029. Taking into account the changes introduced in the oncology package (no limit of chemotherapy services reported), two extreme scenarios were analysed. The first, referred to herein as the maximum scenario, assumed that all person-days of chemotherapy combined with hospitalisation are justified and that they should be included in the forecast. The second, referred to herein as the minimum scenario, assumed that as regards chemotherapy combined with hospitalisation, only the days of administration of the agent are justified, so that the number of person-days of chemotherapy will be lower compared to the maximum scenario.

The results of the forecast for Mazowieckie Voivodeship are shown in Figure 267. The range of potential values of the projected phenomenon is marked in blue. The number of person- days in both scenarios will increase (following an initial decline in the minimal scenario).

52 According to the report on the state of radiotherapy in Poland (as at 31/12/2014), Polish facilities reported that they held or had access to 20 units. 53 At present, the major limitation for the number of PET scans performed is the scope of contracts. The first scenario is a simplified presentation of a situation where the contract is not extended. The second one, however, is based on the maximum potential (calculated on the basis of the currently reported one).

256

Figure 266: Projected number of chemotherapy person-days by 2029

days

of person

Projectednumber

Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

According to the forecast, in the maximum variant, the number of person-days of chemotherapy will increase from 241.6 thousand in 2016 to 267,6 in 2029. In the minimum scenario, the number of person-days will increase from 104.7 thousand in 2016 to 118.4 thousand in 2029.

According to the calculations, in the maximum scenario, the projected share of person-days of chemotherapy in outpatient mode will amount to 4% in 2029, of one-day ones to 22.2%, and of those combined with hospitalisation – to 73.9%.

This is a forecast based only on the structure of services provided in 2012. The changes in the healthcare system that were introduced later and those envisaged currently will improve the future structure of the services provided, in particular by reducing the share of person-days of chemotherapy combined with hospitalisation. Therefore, the forecast for the minimum variant is a more likely approximation of the structure of the chemotherapy services provided in 2029.

257 Figure 267: Projected structure of chemotherapy in the maximum scenario (2029)

outpatient one-day hospitalisations

Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

In the minimum scenario, the share of one-day services is much higher, at the expense of services combined with hospitalisation. According to the calculations, in the minimum scenario, the share of all person-days of chemotherapy in outpatient mode will amount to 8.9% in 2029, of one-day ones to 50.1%, and of those combined with hospitalisation – to 41%.

Figure 268: Projected structure of chemotherapy in the minimum scenario (2029)

outpatient one-day hospitalisations

Source: compiled by DAiS based on data from the NFZ database and the demographic forecast of the Central Statistical Office

As shown, the model includes two chemotherapy forecast scenarios. The optimal number of facilities providing chemotherapy treatment in the region was calculated based on the number of chemotherapy person-days. The national average number of person-days for 2012 served as the current minimum profitable number of person-days.

258 The maximum variant projected an initial rapid increase in the number of person-days of chemotherapy which subsequently levels. The projected number of chemotherapy person- days for 2029 was 267.6 thousand. In the maximum variant, there will be room for 21 new facilities providing such services. One should not forget that the establishment of new facilities is a means to tackle the projected increase in demand for chemotherapy services. Another method is to modernise the existing facilities and to support the shift towards the increased share of day treatment and outpatient chemotherapy in provided treatments. The appropriate approach should take advantage of both described actions.

In the minimum scenario, on the other hand, following an initial decline, there will be a continuous increase from 104.7 in 2016 to 118.4 thousand person-days in 2029. The number of facilities providing chemotherapy services should not increase.

Summary

The maximum variant projected an initial rapid increase in the number of person-days of chemotherapy which subsequently levels. The projected number of chemotherapy person- days for 2029 was 267.6 thousand. There will be room for 21 new facilities providing such services. The increase in demand for new facilities will likely be met in part by expanding and optimising the structure of services provided in the already existing facilities.

In the minimum scenario, following an initial decline, there will be a continuous increase from 104.7 in 2016 to 118.4 thousand person-days in 2029. The number of facilities providing chemotherapy services should not increase.

3.4.4 Radiotherapy Services Forecast

Linear accelerators in Poland in 2014

According to the Report on radiotherapy in Poland by National Consultant for Cancer Radiotherapy, dr hab. med. Rafał Dziadziuszko (as at 31 December 2014) there were 144 linear accelerators deployed in Poland.

Out of 144 accelerators deployed in Poland, most of them were located in Śląskie (25), Mazowieckie (17) and Małopolskie (15) Voivodeships. The fewest were reported in Lubuskie and Opolskie Voivodeships (three each) as well as in Świętokrzyskie and Podlaskie Voivodeships (four each). Linear accelerators were located mainly in major urban hubs, most of them in Warsaw (12), Poznań (12), Gliwice (11), Kraków (10) and Bydgoszcz (9). This is due to the high price of these devices and the qualified personnel required to operate them. The localisation of linear accelerators deployed in Poland is shown in Figure 270. The list of hospitals in Poland with linear accelerators in 2014 is presented in Table 30.

259 Figure 269: Distribution of accelerators in Poland (2014)

Number of accelerators

Source: compiled by DAiS based on the report on the state of radiotherapy in Poland (Gdańsk 2015).

Table 30: Location of accelerators in Poland (2014)

Number of Voivodeship City/town Healthcare provider accelerators

Wrocław Dolnośląskie Oncology Centre 5

Dolnośląskie Legnica Dolnośląskie Oncology Centre – branch 2

Wałbrzych International Oncology Centre 3

Kujawsko- Bydgoszcz Professor Łukaszczyk Oncology Centre 9* Pomorskie

Lubelskie Lublin Lublin Regional Oncology Centre 6

Zielona Lubuskie Lubusz Oncology Centre – Independent Public Healthcare Centre Regional Hospital 3 Góra

Łódź Nicolaus Copernicus Regional Specialist Hospital in Łódź, Regional Oncology Centre 7

Łódzkie Tomaszów NU-MED. Oncology Diagnostics and Therapy Centre 3 Mazowiecki

Maria Skłodowska-Curie Institute of Oncology 4

University Children's Hospital 2 Kraków University Hospital in Kraków, General and Gastroenterological Surgery Ward 1*

Małopolskie Amethyst Radiotherapy Centre 3

Radiotherapy Laboratory with Radiotherapy Ward at the Saint Luke's Provincial Hospital Tarnów 3 Independent Public Healthcare Centre

Nowy Sącz J. Śniadecki Specialist Hospital 1

Warsaw Maria Skłodowska-Curie Institute of Oncology 12

Mazowieckie Wieliszew Mazovian Oncology Hospital 3

Otwock International Oncology Centre 2

260 Opolskie Opole Tadeusz Koszarowski Oncology Centre in Opole 3

Brzozów 1. Specialist Hospital, Bronislaw Markiewicz Subcarpathian Oncology Centre 3 Podkarpackie Rzeszów Fryderyk Chopin Regional Specialist Hospital 3

Podlaskie Białystok Maria Skłodowska-Curie Oncology Centre in Białystok 4

Gdańsk Department of Oncology and Radiotherapy, University Clinical Centre 3 Pomorskie Gdynia Gdynia Oncology Centre at the Polish Red Cross Maritime Hospital 3

Bielsko- Oncology Centre of Beskidy – John Paul II Municipal Hospital 4 Biała

Częstochow Blessed Virgin Mary’s Regional Specialist Hospital 2 a Śląskie Dąbrowa Starkiewicz Specialist Hospital 2 Górnicza

Gliwice Maria Skłodowska-Curie Institute of Oncology 11

Katowice Stanisław Leszczyński Hospital 3

University Ophtalmology and Oncology Centre 3

Świętokrzyskie Kielce Świętokrzyskie Oncology Centre 4

Independent Public Healthcare Centre of the Ministry of Internal Affairs with Warmińsko-Mazurskie Warmińsko- Olsztyn 3 Oncology Centre Mazurskie Elbląg NU-MED. Grupa SA, Centrum Radioterapii i Usprawniania 3

Wielkopolskie Poznań Wielkopolskie Oncology Centre 10*

Euromedic Onkoterapia sp. z o.o. International Oncology Centre 2 Zachodniopomo Szczecin Zachodniopomorskie Oncology Centre in Szczecin Radiotherapy Clinical Department 5 rskie Koszalin Euromedic Onkoterapia - International Oncology Centre 3

Kraków SU Chir, Poznań WCO and F. Ł. Bydgoszcz CO. each had one accelerator for intraoperative radiotherapy only. Source: compiled by DAiS based on data provided by the NFZ and a report on the state of radiotherapy in Poland (Gdańsk 2015).

In 2014, on the national scale, there was one accelerator per over 273 thousand people. This exceeds the recommendations indicated in international guidelines. According to one of the least demanding recommendations, i.e. guidelines of the European Society for Radiotherapy & Oncology of 2005, there should be one linear accelerator in Poland per no more than 250,000 people.54 According to the estimates made by the International Atomic Energy Agency (IAEA) in 2010, in order to fully meet the demand, there should be one accelerator for up to 180,000 people.55 The number of inhabitants per one accelerator in Polish voivodeships in 2014 is shown in Figure 271.

The most favourable ratio of installed linear accelerators to the size of the population was observed in the following Voivodeships: Śląskie (1 per 184 thousand), Zachodniopomorskie (1 per 215 thousand), Małopolskie (1 per 240 thousand) and Warmińsko-Mazurskie (1 per

54 Slotman, Ben J., et al. ’’Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO- QUARTS: work package 1.” Radiotherapy and oncology 75.3 (2005): 349-E1. 55International Atomic Energy Agency.Planning national radiotherapy services: a practical tool.IAEA human health series no. 14. Vienna: International Atomic Energy Agency; 2010, ISBN 978-92-0-105910-9.

261 241 thousand). Only these voivodeships met the 2005 ESTRO recommendations. None Polish voivodeship met the IAEA recommendations. The median for Polish voivodeships was 306 thousand. This means that in one half of the voivodeships there was more people per one accelerator. The situation was worst in Pomorskie Voivodeship (one accelerator per 383,000 people). It was hardly better in Lubelskie (1 per 359,000), Podkarpackie (1 per 355,000) and Lubuskie (1 per 340,000) Voivodeships.

Figure 270: Population (in thousands) per one accelerator by voivodeship (2014)

ESTRO 2005 recommendations:

Met

Unmet

Number of people per one accelerator

Source: compiled by DAiS based on the report on the state of radiotherapy in Poland (Gdańsk 2015), data provided by the NFZ and the Main Statistical Office.

Use of accelerators

In 2014 in Poland, almost 65,000 patients in Poland were treated using teletherapy services. The total only includes patients accounted for within the National Health Fund. Some of the facilities did not report NFZ services in 2014 (Table 30). According to the opinion of the International Atomic Energy Agency (IAEA) of 2010, in order to fully meet the demand, there

262 should be one accelerator for up to 450 patients a year56. Figure 272 shows the number of patients per one accelerator in individual voivodeships, with the voivodeships meeting the IAEA recommendations marked. The service providers who in 2014 did not account for NFZ services or for accelerators intended solely for intraoperative radiotherapy (one in Bydgoszcz, Kraków and Poznań each) were not taken into account.

Figure 271: Number of patients per one accelerator in voivodeships (2014)

IAEA recommendations:

Met

Unmet

Number of patients per one accelerator

Source: compiled by DAiS based on the report on the state of radiotherapy in Poland (Gdańsk 2015), data provided by the NFZ and the Main Statistical Office.

The smallest number of patients per accelerator was recorded in Opolskie (311 per accelerator), Małopolskie (320 per accelerator), Lubuskie (407), Warmińsko-Mazurskie (421), Podkarpackie (422), Podlasie (447) and Dolnośląskie (450) Voivodeships. They were the only

56 IAEA 2010, op. cit.

263 voivodeships in Poland to meet the IAEA estimates (up to 450 patients per accelerator). The value recommended by the IAEA was slightly exceeded by Łódzkie Voivodeship (453 patients per accelerator). The median for voivodeships was 483. This means that in eight voivodeships, the number of patients per accelerator exceeded this value, unlike in the other eight voivodeships. The worst situation was recorded in the two Polish voivodeships with the largest population, i.e. Mazowieckie (583 patients per accelerator) and Śląskie (606 patients per accelerator). The situation was hardly better in Kujawsko-Pomorskie (549 patients per accelerator) and Świętokrzyskie (536 patients per accelerator) Voivodeships.

The number of patients per accelerator in oncology hospitals in 2014 is shown in Figure 273. The service providers who in 2014 did not account for NFZ services (five service providers) or for accelerators intended solely for intraoperative radiotherapy (one in Bydgoszcz, Kraków and Poznań each) were not taken into account. Hospitals with the bars fully against the green background met the 2010 IAEA guidelines (up to 450 patients per accelerator).

Figure 272: Number of patients per accelerator in oncology hospitals in Poland (2014)

peraccelerator Number patients of

Hospitals Source: compiled by DAiS based on data provided by the NFZ and a report on the state of radiotherapy in Poland (Gdańsk 2015).

Out of 30 healthcare providers who, in 2014, reported teleradiotherapy services provided to the NFZ, thirteen did not exceed the limit of the International Atomic Agency. The median for hospitals was 470 patients per accelerator, which means that there were less than 470 patients per accelerator in one half of the hospitals. On average, on a national scale, one accelerator was used to provide services to 494 patients. In twelve hospitals, the number of patients per accelerator exceeded this value. The number of patients per one linear accelerator in hospitals in Poland ranged from 97 to 867.

In the best case scenario, the average number of fractions per patient should be 1857. This allows for estimating the number of fractions per one accelerator in particular Polish hospitals (Figure 274).

57 Barton, Michael et al. (2013), Review of optimal radiotherapy utilisation rates

264 Figure 273: Estimated number of fractions per one accelerator in particular Polish hospitals (2014)

Poland - average

accelerator Fractionsper

Hospitals Source: compiled by DAiS based on data provided by the NFZ and a report on the state of radiotherapy in Poland (Gdańsk 2015).

Estimated number of fractions per one accelerator ranged from 1,611 to 15,960. The average for Poland was 8,892, and the median for hospitals – 8,460.

Technical condition of accelerators

The expected service life of a linear accelerator is 10 years.58 Older units are considered to be obsolete. The more modern ones, technologically more advanced, provide better treatment results. The number of accelerators deployed in Poland by the year of production is shown in Figure 275. Accelerators less than 10 years old have green background, while older ones – red.

Figure 274: Number of accelerators in Poland by the year of manufacture

Number units of

Production year of the accelerator Source: compiled by DAiS based on data provided by the NFZ and a report on the state of radiotherapy in Poland (Gdańsk 2015).

As of 31 December 2014, there were 23 accelerators produced in 2004 at the latest deployed in Poland, which accounted for 16% of the entire national number. Maria Skłodowska-Curie

58 James, Sarah. „A guide to modern radiotherapy”.Published on Society of Radiographers (http://www.sor.org) (2013).ISBN 1- 871101-94-8.

265 Institute of Oncology in Warsaw had most of these, i.e. 4. Professor Franciszek Łukaszczyk Oncology Centre in Bydgoszcz, Maria Skłodowska-Curie Institute of Oncology in Warsaw and Maria Skłodowska-Curie Wielkopolskie Oncology Centre in Poznań each had three accelerators produced before 2005. Dolnośląskie Oncology Centre in Wrocław and Nicolaus Copernicus Regional Specialist Hospital in Łódź, Regional Oncology Centre each had two. One accelerator older than 10 years was deployed in the following facilities: NU-MED Centre for Cancer Diagnostics and Therapy in Tomaszów Mazowiecki, Maria Skłodowska-Curie Institute of Oncology in Kraków, University Hospital in Kraków, General and Gastroenterological Surgery Ward, Tadeusz Koszarowski Oncology Centre in Opole, Fryderyk Chopin Regional Specialist Hospital in Rzeszów and Department of Oncology and Radiotherapy, University Clinical Centre in Gdańsk.

The average age of an accelerator in the voivodeship is shown in Figure 276. The age of the accelerator is defined as the number of years between 2014 and the year of production of the accelerator. The average age of an accelerator in Poland was 5.6 years. The average age of accelerators in Polish voivodeships is shown in Figure 276.

Figure 275: Average age of accelerators in Poland by voivodeship (2014)

Average age of the accelerator

Source: compiled by DAiS based on data provided by the NFZ and a report on the state of radiotherapy in Poland (Gdańsk 2015).

On average, the oldest accelerators were used in Warmińsko-Mazurskie (7.2) and Kujawsko- Pomorskie (7.2) Voivodeships. Wielkopolskie (7) and Łódzkie (6.9) Voivodeships also had high average age accelerators. The median for voivodeships was 6.3 years. On average, the most modern accelerators were installed in Warmińsko-Mazurskie (2.8), Podlaskie (3.3) and Małopolskie (3.8) Voivodeships.

266 Theoretical bases of the optimization model

The availability of radiotherapy services largely depends on the distribution and location of the facilities with the equipment necessary to perform respective services. It also depends on the quality and quantity of the equipment. In the part dedicated to radiotherapy, a negative correlation was shown between the distance of the patient's voivodeship of residence to the nearest linear accelerator and the teletherapy utilisation rate in this county. It also shows a positive relationship between the distance from a facility with an accelerator deployed and the average number of person-days of hospitalisation per cancer patient. These correlations should be interpreted as follows: the longer the distance the patients have to travel in order to receive teletherapy services, the less likely they are to use them and the more likely to use hospitalisation with teletherapy.

The observed correlations imply that in order to improve the quality of treatment of cancer patients, one should consider contracting new teletherapy providers in the cities which currently lack linear accelerators. Such an initiative would allow to reduce the distance to be covered by a patient in order to undergo teletherapy procedures, which should, as a result, increase the teletherapy utilisation rates (i.e. improve the quality of treatment), and reduce the average number of person-days of hospitalisation for teletherapy per patient, which would eliminate unnecessary costs.

To identify the optimal distance between linear accelerators in Poland, an integer-based linear optimisation model was used. The model is designed to minimise the average distance between the patient's county of residence and the facility where s/he is to undergo a teletherapy procedure through the optimal distribution of accelerators in existing facilities and contracting new ones.

The placement model of linear accelerators has been based on the forecast of the number of teletherapy services needed in 2025. The number of teletherapy services in each county was estimated based on the forecast of incidence and teletherapy utilisation rates. The calculation of the rates assumed that for each cancer type and in each county they will be identical to the rates in the whole country (for 2012). This method of projecting the number of services in counties (which is to directly determine the number and placement of accelerators) assumes a standardisation of the access to services and cancer detectability across the country.

For the forecast of the number of services, a placement design plan of accelerators in 2025 was considered such that:

 in the target year (2025), the number of accelerators deployed in Poland was just enough to meet the condition of the IAEA, i.e. the maximum of 450 services (patients)

267 per accelerator per year. The IAEA guidelines use the terms 'patient' and 'treatment' interchangeably. A similar convention is followed in this chapter,

 in the target year, no facility performed more than 450 services using one accelerator,

 each facility had at least two accelerators deployed,

 not to reduce the number of accelerators in the facility.

In addition, the following initial conditions were assumed for the model under discussion:

 in Poland, there are 137 linear accelerators in the facilities contracted by the NFZ and seven accelerators in the facilities having no contracts with the NFZ. Accelerators for intraoperative radiotherapy or the cyberknife type were not taken into account,

 we assume the possibility of deploying accelerators in 51 cities. The group of these cities was established during consultations with the National Consultant and with Regional Consultants for oncological radiotherapy,

 the baseline is 137 accelerators in the respective cities. Cities with accelerators held by the facilities with no contracts with the NFZ may appear in the solution, but only if this was part of a globally optimal solution,

 the distance between counties is calculated in a straight line between county cities,

 the Resolution No. 197/2015 of the Council of Ministers of 3 November 2015 was taken into account, which provides for the deployment of additional accelerators in Lublin in 2019. This means that in the 2025 solution, there needs to be at least eight accelerators in Lublin.

Results of the optimization model

The results of the model of placement optimisation of linear accelerators in Poland in 2025 are shown in Table 31. The cities listed in the "City" column were potential locations of facilities providing teletherapy services covered in the model.

Table 31: Results of the 2016–2025 optimisation model for the purchase and location of linear accelerators

Number of Target number of Voivodeship City/town accelerators by the accelerators in 2025 end of 2015

Jelenia Góra 0 2

Legnica 2 2 Dolnośląskie Wałbrzych 3 4

Wrocław 6 6

268 Bydgoszcz 8 8

Kujawsko-Pomorskie Toruń 0 2

Włocławek 0 2

Biała Podlaska 0 2

Lubelskie Lublin 6 8

Zamość 0 2

Gorzów Wielkopolski 0 2 Lubuskie Zielona Góra 4 4

Łódź 7 7

Piotrków Trybunalski 0 0

Łódzkie Sieradz 0 2

Skierniewice 0 2

Tomaszów Mazowiecki 3 3

Kraków 9 9

Małopolskie Nowy Sącz 2 3

Tarnów 3 3

Wieliszew 3 4

Otwock 2* 2

Płock 0 2 Mazowieckie Radom 0 3

Siedlce 0 2

Warsaw 13 13

Opolskie Opole 3 4

Brzozów 4 4

Podkarpackie Rzeszów 3 4

Tarnobrzeg 0 2

Białystok 4 5 Podlaskie Suwałki 0 2

Gdańsk 4 5

Pomorskie Gdynia 3 3

Słupsk 0 2

Bielsko-Biała 4 5

Częstochowa 2 4

Śląskie Dąbrowa Górnicza 2* 4

Gliwice 10 10

Katowice 3+3* 6

Świętokrzyskie Kielce 4 4

269 Sandomierz 0 2

Elbląg 3 3 Warmińsko-Mazurskie Olsztyn 3 5

Kalisz 0 3

Konin 0 2

Wielkopolskie Leszno 0 2

Piła 0 2

Poznań 10 10

Koszalin 3 3 Zachodniopomorskie Szczecin 5 5 Source: compiled by DAiS based on data provided by the KRN and the NFZ.

Figure 277 shows the distance between linear accelerators in Poland in 2025 in accordance with the optimisation results.

Figure 276: Target number of linear accelerators in Polish cities in 2025 according to the 2016–2025 optimisation model for the purchase and location of linear accelerators

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

By the end of 2015, accelerators were located in three cities in Mazowieckie Voivodeship. There were 13 accelerators in Warsaw, three in Wieliszew, and two in Otwock (without a contract with the NFZ). The model assumed the possibility of establishing a new facility equipped with accelerators in Płock, Siedlce, and Radom, as well as contracting or developing a new facility in Otwock. The results for Mazowieckie Voivodeship indicate that by 2025 the number of accelerators in Wieliszew should be increased (to four), a facility with three accelerators should be opened in Radom, facilities with two accelerators should be opened in Siedlce and Płock), while in Otwock an existing facility should be contracted or a new facility should be established with two accelerators.

270 The discussed model is designed to minimise the average path of the patient in need of teletherapy to the facility providing respective services. Therefore, the placement optimisation of linear accelerators also involves identifying the locations where patients from each county should receive treatment. Locations providing treatment for patients from Mazowieckie Voivodeship in accordance with the 2025 model are shown in Figure 278.

Figure 277: Locations providing treatment for patients from Mazowieckie Voivodeship in 2025 in accordance with the results of the optimisation model of the placement of linear accelerators in Poland

Patients treated in:

No. of patients per county:

Source: compiled by DAiS based on data provided by the KRN and the NFZ.

The projected number of teletherapy healthcare services for the inhabitants of the Mazowieckie Voivodeship amounted to approx. 12.5 thousand for 2025. According to the optimization results, approx. 91.5% of patients from Mazowieckie Voivodeship should receive treatment from Mazovian healthcare providers, approx. 4.5% – from healthcare providers from Łódzkie Voivodeship (Tomaszów Mazowiecki, Skierniewice), approx. 2.5% – from service providers from Warmińsko-Mazurskie Voivodeship (Olsztyn), and approx. 1.5% – from service providers from Lubelskie Voivodeship (Lublin). The optimal number of healthcare services provided in 2025 by Mazovian healthcare providers amounted to 11.7 thousand. According to the model, facilities in Dolnośląskie Voivodeship should provide treatment to 98% of patients from their own voivodeship, to 1% of those from Lubelskie Voivodeship, and to 1% of those from Świętokrzyskie Voivodeship.

Note that the discussed model does not take into account any financial or temporal constraints or private investment opportunities in the years 2016-2025. These issues, in addition to the replacement of obsolete accelerators, should be taken into account in the 'access path', so

271 that the optimal solutions presented above could be met in 2025. The model did not cover proton radiotherapy, which is already implemented in one centre in Poland. Considering cancer incidence prognoses and changes in the treatment method, if the assumed efficacy of proton radiotherapy treatment is confirmed, it would be expedient to open additional centres of this type.

It should also be noted that the model presented in this chapter is intended to minimize the distance that patients need to travel in order to receive teletherapy treatment. It is justified to take such minimization into account when considering the location of accelerators with accuracy to the city rather than the provider. This means that it is impossible to determine the number of accelerators to be deployed in cities where there were at least two healthcare service providers in 2015, as it would involve taking into account assessment criteria other than the distance.

Also, the model does not indicate whether accelerators should be deployed in new hospitals or in those already operating or even in satellite centres of the hospitals already in existence (which solution, considering the declarations regarding the intentions of oncology centres, is highly popular). Meanwhile, the healthcare milieu reports the need to develop radiotherapy in academic centres.

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