Perspectives for Cancer Care and Research in Central and Eastern Europe

Abstract

Background

Discrepancies between the outcomes of cancer patients between Western European and Central and Eastern European (CEE) countries have often been observed. Despite the enormous economic and civilizational progress made in these countries after the abolishment of the communist regime, structural problems persist.

Summary

The present article reviews the domains of medical oncology education, human resources in oncology, cancer care, and clinical research in CEE in order to comprehensively assess the current situation and needs, describe important initiatives, and also propose ways to improving cancer outcomes in the region. Activities are under way to address these issues in national action plans to divert funding into oncology-related education, research, the purchase of equipment, and the attainment of modern hospital organization and structures.

Key Message

Over the past more than 30 years, CEE countries have made enormous economic and societal progress. Nevertheless, challenges especially in the health care sector persist.

Introduction

The present article reviews the domains of medical oncology education, human resources in oncology, cancer care, and clinical research in Central and Eastern European (CEE) in order to comprehensively assess the current situation and needs, describe important initiatives, and also propose ways to improving cancer outcomes in the region.

Education of Oncologists in CEE

The best care for cancer patients is achieved when diagnostic procedures and different treatment modalities are provided by well-trained and qualified specialists working together in a multidisciplinary team. The education in oncology starts at the medical school as undergraduate education. Since there is no uniform curriculum for undergraduate education in oncology in Europe, substantial differences in undergraduate oncology teaching may appear. While the results of a survey performed at the turn of the century revealed that oncology was present in the medical students' core curricula in only 41 out of 100 institutions taking part in the survey, data from a more recent period show a progress [1]. The survey conducted among academic teachers at 32 institutions from 19 European countries revealed that oncology was taught as either an independent discipline or along with other disciplines at all institutions in all participating countries. This includes 7 CEE countries (Croatia, Czech Republic, Poland, Romania, Serbia, Slovakia, and Slovenia) [1]. Nevertheless, it is important to note that the time devoted to oncology-related topics significantly varied among institutions and countries. At this point, CEE countries seem to perform quite well, with Poland institutions reporting the highest number of hours (approx. 120) devoted to teaching oncology per scholar year among the participating countries. In all other CEE countries, except Hungary, the number of hours devoted to oncology seems to be in the upper part of the average.

In contrast to undergraduate education, there is an aspiration to deliver uniformly high cancer care across Europe by harmonizing postgraduate education in oncology. The European Union of Medical Specialists (UEMS) set up European training requirements for the specialty of radiation oncology and the specialty of medical oncology [2], while the recommendations on curricula, including the length of the specialization and the competencies that need to be acquired, have been made by various societies. The European Society for Radiation Oncology (ESTRO) developed a core curriculum for radiation oncology [3], while the European Society for Medical Oncology (ESMO) in collaboration with the American Society of Clinical Oncology (ASCO) developed a global curriculum in medical oncology [4]. Both specialties were quickly recognized and introduced in a vast majority of CEE countries. Based on the survey performed in 2014, radiation oncology was recognized as a standalone specialty in 7 (Bulgaria, the Czech Republic, Hungary, Poland, Romania, Serbia, and Slovakia) out of 8 participating CEE countries [5]. Only in Croatia, radiation oncology continued to be a part of the common oncology specialty on Clinical Oncology. Unfortunately, some CEE countries with a long tradition of specialty training in radiation oncology, such as Slovenia where radiation oncology was recognized as a standalone specialty already in 1957, were not part of the survey. Given the fact that radiation oncology was recognized as a standalone specialty in only 21 out of 28 participating European countries, the situation in CEE countries seems good. The length of the specialization was in line with the recommended 5 years in the vast majority of CEE countries, and the number of new trainees per year in CEE countries did not differ much from the numbers in the Western European (WE) countries.

Even though medical oncology has been recognized as a separate specialty by the European Union (EU) only in March 2011, many CEE countries were among the pioneers in setting up medical oncology as an independent specialty much earlier. In Slovenia, medical oncology was recognized as independent specialty with an established national curriculum already in 2000, while in Croatia, subspecialty training in medical oncology was set up even earlier in the late nineties. Based on the results of a global survey performed by the ESMO/ASCO global curriculum (GC) working group in 2019 [6], medical oncology was recognized as a standalone specialty in all CEE countries (Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Hungary, Montenegro, Poland, Romania, Serbia, Slovakia, and Slovenia). At that time, the ESMO/ASCO GC on medical oncology was fully or partly adopted in a vast majority of CEE countries (Fig. 1a, b). Out of 11 CEE countries, only Bulgaria, Poland, and Romania did not adopt ESMO/ASCO GC into their national curricula. In all CEE countries, the duration of training in medical oncology was in line with the EU Directive and ESMO/ASCO GC recommendations, i.e., a minimum duration of 5 years. It is encouraging that the range of countries that recognize medical oncology as a standalone specialty in the CEE region is comparable to the WE region and much higher compared to the average rate of medical oncology recognition of 75% worldwide. In terms of ESMO/ASCO GC adoption, the adoption rate in CEE countries is quite comparable to the 68% rate reported for all participating countries as well as to the adoption rate observed in the WE countries. There is still room for improvement in the adoption of GC in the whole of Europe and by large in CEE countries in which awareness about GC ability to unify training and decrease inequities in cancer care still needs to be strongly advocated. In addition, only in Slovenia among the CEE countries and Switzerland among the WE countries, ESMO examination is a mandatory part of the final exam in medical oncology. The incorporation of the European examination in the final exam might enable CEE countries to further improve professional standards and qualifications and ease free movement of well-trained specialists across borders.

Fig. 1.

a Recognition of medical oncology (MO). Dark blue: MO recognized as specialty. Blue: MO recognized as subspecialty. Green: MO trained in clinical oncology. Yellow: MO trained in haemato-oncology. Purple: MO not recognized. Gray: no information. b Adoption of ESMO/ASCO global curriculum (GC) in medical oncology. Dark blue: GC fully adopted. Blue: GC partly adopted. Green: GC adapted. Yellow: GC adopted but trained abroad. Purple: GC not adopted. Gray: no information. Adopted from Cufer et al. [6] and reproduced under CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Surgical oncology is not recognized as a specialty in the EU. In most European countries, surgical specializations are organ based and are likely to remain so in future. To increase professional competence in oncology, the European Society of Surgical Oncology (ESSO) developed a core curriculum in surgical oncology [7]. The curriculum contains all aspects of multidisciplinary cancer care, with the focus on surgery, needed for future candidates who plan to train and eventually sit for the European exam in surgical oncology. The exam is organized jointly by the Oncology Division of the European Board of Surgery (EBS) and UEMS and offers candidates the European Board of Surgery Qualification (EBSQ) in surgical oncology. Unfortunately, the participation of surgeons from CEE countries in this exam is not as high as the participation from other European countries. In recent years, mainly candidates from Slovenia, Hungary, and Croatia took part in the exam, while participation from other CEE countries was poor or nonexistent [7]. Therefore, increased awareness of this exam and stimulation of young surgeons from CEE to take the exam are warranted.

In addition to undergraduate and postgraduate education, there are multiple courses on different topics of oncology at which oncologists from the CEE region can get added knowledge and skills. The European School of Oncology (ESO) organizes specific courses dedicated to young oncologists from the CEE region, while ESMO, in the period 2016–2019, led a particularly useful specific Integration Fellowship program dedicated to young oncologists from the countries which joined the EU after 2004. The interest of young oncologists from the CEE region in those courses and fellowships is rather high; however, based on competitive principles, only the most committed candidates manage to get places on those courses. The education of other professions taking part in multi-professional cancer care in CEE seems to be quite comparable to the education in WE countries, as well. The ESTRO GC makes the nonmedical experts' role more explicit [3], and in countries with recognized radiation oncology as a specialty, which CEE countries are, physicists and radiotherapy technicians are also educated according to those proposals. Oncology nurses from most CEE countries are members of the European Oncology Nursing Society (EONS) and some of them took a leading role in preparing the EONS Cancer Nursing Education Framework program [8]. The status of oncology pharmacy varies widely both globally and at the European level. The need for harmonized and EU-recognized oncology pharmacist training and education was identified as an important issue. An important step forward was the creation of a comprehensive educational program for pharmacists named the European Specialization in Oncology Pharmacy by the European Society of Oncology Pharmacy [9]. This is especially important in countries where oncology pharmacy as a specialty is still developing, as is the case in many of the CEE countries, where oncology-specific board-certified pharmacists practicing in oncology are not yet common.

Taken together, the overall conditions for education of oncologists in the CEE region seem rather good. Both basic specializations, radiation oncology and medical oncology, are recognized in almost all CEE countries, and oncologists have many opportunities to upgrade their knowledge within the framework of various courses and fellowships. Additionally, the internet and social networks nowadays can supply unlimited access to international literature and learning resources. Despite this, an open question remains as to why these relatively satisfactory educational conditions do not result in a comparable level of cancer care in CEE compared with WE countries. The reasons for this are certainly the lack of personnel and money, but important reasons certainly remain the insufficient involvement of oncologists from the CEE region in international research and development activities after completing their formal training and a lack of education and skills on fundamentals of cancer care organization, adjusted to available resources. To improve cancer care in CEE, it is imperative to focus efforts on improving the education of both oncologists and other health care system providers in the field of cancer care organization. With this in mind, it is truly encouraging that various organizations, such as ESMO and ESO, provide educational leadership programs for young oncologists, and especially that CECOG developed the so-called Open CEEiling leadership program [10] for future leaders in oncology for young oncologists from the region of Central and Southeastern Europe.

Human Resources in Oncology in CEE

Higher wealth and higher health care expenditures are associated with both increased cancer incidence and decreased cancer mortality within the EU [11]. Inequality in care leads to up to 40% higher cancer survival rates in WE than in CEE [12]. Postcommunist political, economic, and social transformation has led to a gradual improvement in health system outcomes in CEE countries over the last few decades [13]. Human resources not only account for a substantial proportion of health care expenditures but also represent the most important input into the provision of health care [14]. The positive recent overall trends in health system outcomes in CEE countries may occur at the cost of the overwhelming workload pressure on health professionals, including oncologists, and on the corresponding health care infrastructure.

Medical oncologists play an essential role in the multidisciplinary oncologic team, which is required for high-quality cancer care and cancer research [15]. The suggested international maximum annual caseload of new patient consults per medical oncologist is between 150 and 175 [16]. The key findings of the recent global study which also investigated the clinical workload of European medical oncologists were the following: (i) the median number of annual consults per medical oncologist is 225 in CEE countries compared with 175 in WE countries (p < 0.001), (ii) the proportion of medical oncologists seeing more than 300 consults/year is 35% in CEE countries compared to 18% in WE countries, (iii) the median number of patients seen in a full day clinic is 25 in CEE countries and 15 in WE countries (p < 0.001), and CEE medical oncologists report spending a median of 25 min per new consultation compared with 45 min in WE (p < 0.001) [17]. It is concerning that a half of medical oncologists in the CEE see several hundred new cases instead of the proposed reasonable new case volumes (175–225 new consults per year) [17]. Moreover, a gap in the workload of medical oncologists between CEE and WE countries might further widen in the near future. In WE countries, the average mean annual increase in the total number of medical oncologists was 5.3% (range: 1.8–8.7%) during the last decade [18]. Unfortunately, no comprehensive information about the future planning of the medical oncology workforce is currently available for CEE.

Radiotherapy is a capital-intensive cancer treatment modality which requires both sufficient infrastructure and specialized and trained personnel including radiation oncologists, medical physicists, and radiation therapy technologists. The aim of the ESTRO QUAntification of Radiation Therapy infrastructure and Staffing needs (QUARTS) project was to provide health care planners and policymakers with objective estimates of infrastructure and staffing needs for radiotherapy [19]. It was suggested that one linear accelerator could serve 450 patients annually, whereas the personnel needs were defined as one radiation oncologist per 200–250 patients and one physicist per 450–500 patients [20]. In the year 2010, the ESTRO Health Economics in Radiation Oncology (HERO) project was launched to conduct a detailed evidence-based estimation of radiotherapy infrastructure and personnel in Europe. Final results of this project show that the average staffing figures in Europe are now consistent with, or even more favorable than the QUARTS recommendations [21]. However, there are large variations between countries for most parameters studied. For example, averages and ranges for personnel numbers per million inhabitants are 12.8 (range: 2.5–30.9) for radiation oncologists, 7.6 (range: 0–19.7) for medical physicists, and 26.6 (range: 1.9–78) for radiation therapy technologists. Radiation oncologists on average treat 208.9 courses per year (range: 99.9–348.8), physicists and dosimetrists conjointly treat 303.3 courses (range: 85–757.7) and radiation therapy technologists 76.8 (range: 25.7–156.8). In less affluent countries, including CEE, all personnel categories treat higher courses per annum than in wealthier WE countries [21]. Results of the ESTRO HERO reflect differences between CEE and WE countries in cancer incidence, socioeconomic situation, stage in technology adoption, and the different professional roles and responsibilities within each country.

Currently, there are no high-level data available for the workload and staffing in surgical oncology and oncologic nursing in the CEE. However, it is encouraging to see recent initiatives of intensive networking of surgeons in the CEE. The Central Eastern European Breast Cancer Surgical Consortium (CEEBCSC) was officially established in 2018, and the main aims of the consortium are to increase the quality of breast surgical care in the region and to facilitate international breast surgical scientific relationships and education and training of breast surgeons [22].

In the coming years, the workforce needs across Europe may further increase due to professional burnout. Published data suggest that the rate of burnout has been increasing among physicians over time [23]. According to the results of a recent survey, 72% of oncologists in the CEE were at high risk for burnout and younger oncologists are the most vulnerable group [24].

An analysis of the European Commission found that the migration of health professionals is especially pronounced from Eastern and Southern Europe to wealthier Western and Northern European countries. It is also concerning that 39–85% of medical students from Eastern Europe plan to seek employment abroad after their graduation [25, 26]. These observations may not only negatively affect medical oncology directly but also indirectly, as contemporary cancer care is becoming strongly dependent on other segments of health care.

In the following years, demand for oncology services is expected to rise further as result of population aging, introduction of both new technologies and novel therapeutic drugs and improvements in cancer survival rates. European health policymakers and national governments should jointly initiate appropriate activities to reduce disparities between CEE and WE countries and to ensure a sustainable future of the oncology workforce in Europe, especially in the CEE.

Cancer Care in CEE

Several studies have demonstrated profound disparities in cancer care across Europe, which mainly result from wealth differences between WE and CEE countries [27, 28, 29]. Until the early 1990s, the CEE countries were part of the former Soviet Union or were under its influence. This resulted in their socioeconomic underdevelopment. After the abolishment of the communist regime, countries of this region have made enormous economic and civilizational progress, and some became high-income countries. Nevertheless, on average, the financial situation still greatly favors WE.

Most CEE countries have a social security-based health care system, delivering health care via public funds. Even after adjustments for purchasing power parity, the per capita health care spending differed in 2019 five-fold between the richest and poorest EU countries: €70 in Romania versus €352 in Luxembourg [30]. Annual per capita expenditures on cancer drugs ranged from around €13 to €16 in Czechia, Latvia, and Poland to about €92 to €108 in Austria, Germany, and Switzerland. Expenditures on oncology care in CEE countries have been steadily increasing, and differences in oncology spending across Europe have grown smaller. However, a rapid rise in treatment costs has largely nullified this increase.

One of the prerequisites for improving cancer outcomes at the population level is the development of comprehensive national cancer control plans. However, by 2016, seven of 13 CEE countries did not develop cancer control plans compared to 90% in WE [31]. Additionally, some CEE countries that have created plans have faced problems in their implementation. Finally, comprehensive population-based cancer registries are not available in all CEE countries, and their validity and reliability are uncertain.

Approximately 50% of cancers can be prevented. However, many CEE countries cannot afford to implement effective prevention measures. Screening for cervical cancer, breast cancer, and colorectal cancer in most CEE countries has either been introduced late or not launched. Additionally, screening participation by targeted populations remains too low to reduce overall mortality from these malignancies.

Access to novel anticancer drugs remains lower in CEE than in WE countries, and these figures have not changed over time [30]. Again, the major factor contributing to inequity of access to anticancer medications is their cost and affordability [32]. This also applies to countries within CEE, favoring those with higher incomes [33]. A critical issue in medical oncology in CEE is an insufficient number of specialists, making their clinical workload substantially higher than in WE [17].

Another gap in cancer care in Europe is radiotherapy. Many CEE countries face critical shortages of equipment, particularly state-of-the-art machines. The ESTRO HERO project showed a clear relation between socioeconomic status and the availability of radiotherapy equipment [34]. The number of megavoltage units per million inhabitants ranged in 2014 from 1.4 in Albania and 1.8 in Bulgaria to 8.3 in Norway and 9.5 in Denmark.

An important shortcoming of oncology care in CEE countries is their archaic organizational structure. For example, according to Eurostat, in 2016, CEE countries had, on average, a higher number of hospital beds than WE countries, e.g., 603, 314, and 215 per 100,000 population in Bulgaria, France, and Sweden, respectively. However, this is not an indicator of abundance but rather wasteful use of resources by maintaining Soviet-style hospital-based care instead of less costly ambulatory or day hospital treatment [35].

The shortfalls mentioned above, result in persistently poor cancer treatment outcomes in CEE countries. For colon cancer, the average 5-year survival rates in CEE and WE countries are 52% and 63%, respectively [36], and for breast cancer are 75–77% and 82–87%, respectively [37]. For all types of cancer, the 5-year survival rates range from 40% in Bulgaria to 64% in Sweden [38].

Cancer incidence and mortality across Europe show significant differences; the overall incidence is higher in WE, whereas the mortality is higher in CEE [39, 40]. Further, overall cancer mortality has generally been decreasing in WE, whereas in CEE has reached a plateau or is growing [41]. The mortality to incidence ratio, a surrogate for treatment outcomes, ranges from 0.30 to 0.37 in WE to 0.37–0.56 in CEE and is strongly related to GDP in each country [31]. According to 2016 estimates, increasing overall cancer survival in countries with low rates to the EU median would have avoided approximately 50,000 additional cancer deaths per year [41].

Lower efficacy of cancer treatment in CEE has often been attributed to variations in cancer detection and later stage at diagnosis. However, in a large observational study including 15 European countries, the risk of death in CEE countries was still higher after adjusting for age, sex, and cancer stage [42]. These results strongly suggest inadequate cancer management as a major cause of poorer outcomes in CEE.

Facing financial barriers and fundamental cancer care shortcomings, patients and their families in CEE have developed several coping strategies to access diagnostics and modern therapies. These include paying out of pocket, visiting a private practitioner, or referring to informal payments or personal connections [43]. Patients in CEE also express distrust about cancer treatment and its success. A good illustration of these attitudes is a survey comparing the public perception of cancer treatment in Poland and Austria [44]. Both countries are members of the European Union but show high differences in health-related per capita spending. Polish, compared to Austrian patients, less frequently positively rated overall treatment efficacy (29% vs. 80), hospital care (44 vs. 84%), and ambulatory care (28 vs. 76%), respectively. Only 10% of Polish, compared to 48% of Austrian patients, believed that treatment offered by their health care system was equivalent to that in other EU countries.

Clinical Research Activity in CEE Countries: Current Status and Further Perspectives

Clinical research is a complex process that relies on many organizations and factors. Due to its multifactorial determinants, the assessment of the research activities remains controversial [45, 46, 47]. In a specific region or country, the access to the clinical trials may partially reflect the clinical research performance. Important concerns in performing clinical trials in the CEE region were put forward in the early 2000s [48], but nowadays, the situation has dramatically changed. However, some disparities in the access to oncology clinical trials are still present across the European countries. For example, during 2009–2019, 18.454 clinical trial entries were noted in Europe, of which 78% were phase II and III [49]. In the CEE countries, the distribution of the clinical trial entries is heterogenous. Less than 200 trial entries were noted in Bulgaria, Slovakia, Serbia, Croatia, Lithuania, Latvia, Estonia, Slovenia, Bosnia and Herzegovina, Macedonia, Albania, and Montenegro, between 200- and 500 trial entries were documented in Romania, whereas between 500 and 1000 trial entries were noted in Hungary, Czech Republic, and Poland. Of note, countries with >1000 trial entries are found only in WE. When the distribution was adjusted according to the number of inhabitants per country, the heterogeneity was still preserved. Per 100,000 inhabitants, <1 clinical trial was noted in Bosnia and Herzegovina, North Macedonia, Montenegro, and Albania; between 1 and 3 clinical trials were recorded in Serbia, Romania, Croatia, Poland, Slovenia, Lithuania, Bulgaria, Slovakia, and Latvia; and between 4 and 6 in Estonia, Hungary, and the Czech Republic. Of note, two countries stand out with the highest clinical trials/100,000 inhabitants: Hungary with 5.26 and the Czech Republic with 5.28. Noteworthy, the majority of countries with 5–10 trials/100,000 inhabitants belong to the WE. Evaluating the trend of clinical trials/100,000 inhabitants according to the gross domestic product (GDP), a positive correlation was found across the European countries in general. However, discrepancies remain in the CEE region with consistent differences in the number of clinical trials related to similar average GDP per capita. For instance, for the interval 15–20k USD/capita, there are 5.26 and 5.28 trials/100,000 inhabitants for Hungary and the Czech Republic and 2.18 and 2.8 trials/100,000 inhabitants in Poland and Slovakia. At a European level, a positive correlation between the number of trials and cancer incidence was found. In the CEE region, this correlation could not be confirmed. For cancer incidence between 550 and 650 age standardized rate/100,000, we find the Czech Republic and Hungary with the highest number of trials (>5/100,000) as compared with Croatia (1.84/100,000), Slovenia (2.47/100,000), and Slovakia (2.8/100,000). The dynamic in the number of clinical trials during 2010 and 2018 is also heterogenous in the CEE region. Only 2 countries showed a positive growth rate, Poland (growth rate 0.34), and the Czech Republic (growth rate 0.24), whereas all other CEE countries showed a negative trend, suggesting an overall contraction in the number of clinical trials during this period.

Another way of evaluating the research performance is by looking at the number of the published articles and their international impact. Such an evaluation was performed using the Web of Science for the Science Citation Index Expanded and the Proceedings for the years 2007–2016 [50]. The distribution of the oncology-related papers, the annual average percentage growth, and the cancer research activity as a fraction of all biomedical research in the CEE countries are presented in Table 1.

Table 1.

Number of oncology papers, annual average percentage growth, cancer research activity as a fraction of all biomedical research

	Oncology papers, n	AAPG	%BM
Poland	11,585	6.7	12.6
Czech Republic	5,352	5.5	12.0
Hungary	3,085	5.1	10.5
Romania	2,875	15.0	12.6
Serbia	2,299	7.0	12.5
Slovenia	1,546	4.7	11.2
Croatia	1,481	−0.9	10.0
Slovakia	1,304	10.7	10.7
Bulgaria	776	0.6	8.6
Lithuania	575	14.0	9.1
Latvia	255	15.2	13.8
Estonia	253	13.1	4.5

Reprinted from Begum et al. [50]. Copyright 2022, with permission from Elsevier. AAPG, annual average percentage growth; %BM, cancer research activity as a fraction of all biomedical research.

One can notice that Poland is by far the leading country, with the highest number of published papers, followed by the Czech Republic and Hungary. On the other hand, the highest growth rate was recorded in Romania and the Baltic countries, whereas the lowest was found in Croatia and Bulgaria. Interestingly, the cancer research activity as a fraction of all biomedical research looks pretty similar across the majority of CEE countries (around 10–12%), excepting Estonia, where it was 4.5%. Research outputs tend to correlate fairly with the GDP and population size. In the majority of CEE countries, the amount of international cooperation with other EU states is around 60–78%, excepting Latvia and Estonia, where it is close to 50%. For most of the CEE countries, international collaboration has increased in the period between 2012 and 2016 when compared with 2007–2011, especially in Bosnia and Herzegovina, Slovenia, and Croatia.

On the other hand, the impact of the published research activity, according to the citation scores, shows a different pattern (Table 2). The Czech Republic and Hungary are still at the top (with a mean “world-scale” [WS] score of 40.6 and 33.1). However, Poland (the first according to the number of papers) had a mean WS score of 26.8, whereas the Baltic countries (the last according to the number of publications) had a high WS score, in the range of 31.2–21.8.

Table 2.

The impact of the published research activity, according to the citation scores (adapted from Begum et al. [50])

	ACI	GCI	Mean WS
Czech Republic	11.4	6.0	40.6
Hungary	10.3	5.2	33.1
Estonia	10.8	6.0	31.2
Poland	8.0	3.5	26.8
Slovenia	8.7	4.4	26.1
Lithuania	6.1	2.9	22.6
Latvia	7.8	4.1	21.8
Slovakia	8.0	4.0	19.5
Croatia	6.2	2.9	17.4
Romania	5.5	2.6	14.1
Bulgaria	6.0	3.0	8.7
Bosnia and Herzegovina	2.9	1.2	5.0

Reprinted from Begum et al. [50]. Copyright 2022, with permission from Elsevier. ACI, actual citation impact (arithmetic mean); GCI, geometric mean citation; WS, world-scale (see Begum et al. [50] for methodology).

When the amount of cancer research was evaluated according to the main anatomical sites and the percentage of their burden, malignant melanoma, the central nervous system, and blood cancers dominate relative to other cancers, whereas pancreatic, gastric, and esophageal cancer are underrepresented by a factor of at least two and lung cancer by a factor of more than four.

When the citation scores were classified according to the research domain, the most consistent international impact was obtained for the targeted treatments and other “clinical trials” (5-year mean citation score, actual citation impact >80%), whereas other domains like epidemiology, screening, palliative care, and quality of life have a low representation (actual citation impact<20%).

One can conclude that in the CEE countries, participation in clinical trials is reasonable but needs improvement. Factors associated with the negative growth rate in some countries should be identified, and specific measures should be taken to counteract this trend. The positive experience from the Czech Republic and Hungary needs to be shared with the rest of the CEE countries. National oncology societies and patient organizations should exert pressure on the governmental and health authorities to perceive the research activity as part of the quality of the health care system [51] and a strategy for providing a more affordable cancer care [52]. Therefore, they must assume the responsibility of establishing efficacious means to sustain the logistical and financial needs of the current research sites and to stimulate the foundation of new research units in the academic [53] and nonacademic medical institutions. This support should be subject of specific “official” plans, with clear, defined objectives, initiatives, timelines for implementation, financial resources, and responsibilities. In Romania, e.g., the recently elaborated “National Cancer Control Plan” recognizes the lack of investments in clinical research, but specific directions of action are not clearly stated [54].

Tumor registries should be considered a priority, and more resources should be allocated in countries where this important reference tool is not operational [55]. Epidemiological studies are mandatory for providing data on the country-specific tumor burden and morbidity trends, which may be used to elaborate specific clinical trials oriented toward addressing the national needs. Cooperation with other EU countries is paramount, but some regional specific drawbacks can be identity following regional cooperation [55]. Besides the industry-sponsored trials, the academic-driven research is expected to contribute more, especially in the fields of palliative care, quality of life, and screening which are underrepresented in the CEE space as compared with other EU countries.

Conclusion

Over the past more than 30 years, CEE countries have made enormous economic and societal progress. Nevertheless, challenges especially in the health care sector persist. Research has been conducted to better understand the causes of these challenges and to propose solutions. As a consequence, educational initiatives aiming at a standardized, high-quality education in medical oncology, surgical oncology, and radiation oncology have been implemented. Despite these educational efforts and in conjunction with the economic precariat, health care professionals in the region face a higher workload, higher risk of brain drain, and lower research activity compared to WE countries. However, activities are under way to address these issues in national action plans to divert funding into oncology-related education, research, the purchase of equipment, and the attainment of modern hospital organization and structures.

Conflict of Interest Statement

T.C.: receipt of honoraria or consultation fees from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Roche, MSD, Pfizer, and Takeda; B.S.: honorary and consultancy fee from Astellas, Jansen, and AstraZeneca; M.D.: advisory role and speaker fees from Aventis, Astellas, AstraZeneca, Amgen, Ipsen, Janssen, Novartis, Pfizer, Roche, Sandoz, BMS, MSD, Eli Lilly, Servier, and Takeda; J.J.: advisory roles in AstraZeneca, MSD, and Exact Sciences. C.T and C.C.Z.: institution (CECOG): BMS, MSD, Pfizer, AstraZeneca, Merck KgA, Amgen, Servier, Eli Lilly, Takeda, Daiichi Sankyo, Roche, Boehringer Ingelheim, Celgene, and Halozyme. C.C.Z.: consultancies and speaker's honoraria from Athenex, MSD, Imugene, AstraZeneca, Servier, and Eli Lilly; patents for Imugene.

Funding Sources

The authors did not receive funding for this work.

Author Contributions

T.C. contributed the chapter on education of oncologists in CEE. B.S. wrote the chapter on human resources in oncology in CEE. J.J. prepared the chapter on cancer care in CEE. M.D. contributed the chapter on clinical research activity in CEE countries: current status and further perspectives. C.T. contributed to agreement to be accountable for all aspects of the work. C.T. and C.C.Z. contributed to drafting the work and revising it critically for important intellectual content and final approval of the version to be published.

Funding Statement

The authors did not receive funding for this work.