HealthManagement, Volume 21 - Issue 4, 2021

360 Health Analysis - Breast Cancer Management in Portugal: Patient Journey

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Introduction: 360 Health Analysis (H360) was started in 2018 with the aim of providing a comprehensive picture of breast cancer management in Portugal. After initial evidence retrieval (Phase 1), this study (Phase 2) focused on analysing hospital organization and performance on breast cancer management from the perspective of patients, health care professionals (HCPs), and hospital decision-makers, with the aim of identifying the main difficulties experienced by health and social support structures in this setting. The final goal is to put forward a national consensus with an action plan on how to improve breast cancer management in Portugal


Methodology: Voluntary surveys were carried out to breast cancer patients, as well as interviews to HCPs and hospital decision-makers in seven Portuguese hospitals. Patients received the survey by telephone or email and data was subsequently quantitatively analysed using descriptive and comparative statistics. HCPs and hospital decision-makers were personally interviewed, and data subsequently qualitatively analysed.

Results: A total of 98 patient surveys, 22 HCP interviews, and five hospital decision-maker interviews were conducted in the seven hospitals included in the study. Most patients reported using their own vehicle or public transport to commute to and from the hospital, with a commuting time longer than 1 hour in 21% and 15% of cases, respectively. Waiting time until treatment start was longer than 1 hour in 35% of cases. In the hospital, patients’ first contact when going to treatment was mostly services’ front desk. Eighteen percent of women continued working while undergoing breast cancer treatment. HCPs from all hospitals acknowledged multidisciplinary disease management as a reality in their institutions. Both HCPs and hospital decision-makers acknowledged attending an excessive number of patients for their hospital capacity (in terms of facilities and technical or human resources), as well as long waiting times for performing complementary diagnostic exams and retrieving results.

Conclusions: This study revealed unmet needs regarding accessibility of breast cancer patients to the hospital and in their journey within the Portuguese health system. Some can potentially be addressed by hospital administrations participating in this study or through national political or legal measures.



360 Health Analysis (H360) was started in 2018 with the aim of providing a comprehensive picture of breast cancer management in Portugal by retrieving real-world data from Portuguese hospitals. Phase 1 of this project consisted in a comprehensive review of the state of the art regarding clinical practice, management, and quality of care in breast cancer in Portugal (Coelho et al. 2020). H360 Phase 2 intends to document how the Portuguese health system currently performs regarding breast cancer management, from screening and diagnosis to treatment and follow-up. It also aims to identify the main difficulties experienced by the health system in this endeavour and put forward an integrated multi-institutional action plan on how to improve breast cancer management in Portugal. To do so, the present study analysed hospital organisation and performance regarding breast cancer management from the perspective of patients, health care professionals (HCPs; clinicians and non-clinicians), and hospital decision-makers. The study aim was to analyse how patients perceive their journey within the health system, from breast cancer diagnosis to treatment and follow-up, and also how HCPs and hospital decision-makers perceive the journey of these patients within their institutions. Data regarding both these aspects represents an unmet need in Portugal, as there is a clear lack of literature and studies on the subject. European and international studies published in this area are scarce and usually related to the process of breast cancer diagnosis (Heisey et al. 2011; Burgess et al. 1998; Arndt et al. 2003)


This study was approved by the Administration Boards of participating hospitals following approval by the respective Ethics Committees and its design and conception were of the strict responsibility of study investigators. Voluntary surveys were carried out to breast cancer patients and faceto-face interviews to HCPs and hospital decision-makers in Portuguese hospitals. Of 10 initially selected hospitals, three were excluded due to successive bureaucratic and Ethic and Data Protection Commission response delays and seven were included, comprising general university hospitals (n=1), district hospitals (n=3), oncology institutes (n=2), and private hospitals (n=1). Hospital institutions were anonymised to ensure data privacy. 

1. Patient surveys 

Patient inclusion criteria for participating in the survey included women (i) with breast cancer diagnosis, (ii) aged ≥18 years old, (iii) with a first cancer diagnosis, (iv) with breast cancer diagnosis ≥6 months and ≤5 years ago, and (v) able to provide written informed consent. No exclusion criteria were set. Sampling was done by convenience for patients attending the Oncology consultation, meeting study inclusion criteria, and accepting to participate in the study. The intention was to select a 3:4 proportion of patients with early and advanced stage disease. Based on the initial hospital sample of 10 hospitals and in the 1.72% prevalence of breast cancer in Western Europe (Bray et al. 2013), the estimated sample size was between 263 and 332 patients. Sample estimation was set for a bilateral test, with 0.05 probability of type I error and 0.95 potency. G*Power® Software was used for calculations. Based on these considerations, sample size was 300 patients. After exclusion of three hospitals and considering the number of patients answering the survey (n=98), study potency was set at 0.84. Patients received the survey either by email or telephone between 1 and 23 of June 2020. Online interviews were carried out with Computer Assisted Web Interview (CAWI) system and phone interviews with Computer Assisted Telephone Interview (CATI) system. Quantitative study using descriptive and comparative statistics was subsequently performed using SPSS® software. 

2. Health care professional (HCP) interviews 

To gain insights from HCPs on patients’ journey within the health system, including main barriers and facilitators, a qualitative methodology was used, through implementation of semi-structured interviews with presentation of a standardised case vignette. Inclusion criteria comprised professionals (i) with direct intervention in breast cancer care in the study hospitals (ii) belonging to one of the following professional categories: diagnostic technician, nurse, nutritionist, operational assistant, pharmacist, psychologist, physician, physiotherapist, social worker, or technical assistant.

HCPs meeting inclusion criteria were randomly invited to participate in the study on the day of study interview until the pre-defined sample size for each hospital was reached. Considering the number of professional categories established in inclusion criteria, the prespecified sample size was three HCPs per hospital, in a total of 30 HCPs. Qualitative analysis of interview contents was subsequently performed based on breast cancer patient journey. 

3. Hospital decision-maker interviews 

To retrieve the perspective of hospital decision-makers regarding hospital procedures and performance in breast cancer management, a qualitative methodology was used, through implementation of semi-structured interviews. Inclusion criteria comprised professionals (i) performing hospital decision-maker functions (ii) in one of the following settings: Administration Board, Management Support Unit, Department direction, or Clinical management/direction. Sample was prespecified at one hospital decision-makers per hospital, in a total of 10. Qualitative analysis of interviews’ contents was subsequently carried out. 


1. Patient surveys 

1.1 Hospital selection and patient interviews 
A total of 155 patients accepted to participate and were enrolled in the study. Of these, 98 patients were successfully contacted, either by email or telephone. The flowchart of patient enrollment is depicted in Figure 1. 

1.2 Patient socio-demographic characterisation 
The median age of women included in this study was 59 (range 35−85) years old and most lived in the north of Portugal (33%) or Lisbon (32%; Table 1). Regarding household, 44% of women lived in households of two people, 23% of three, 13% of four or more, and 20% of patients lived alone. A significant proportion of women (58%) were married or lived with a partner, 16% were single, 13% were divorced, and 13% were widows. The predominant household net monthly income was ≤800€ (30%), followed by 800−1200€ (23%). Most women (81%) had descendants (two descendants in 41% of cases and one descendant in 40% of cases). Most women (53%) had their breast cancer diagnosed <4 years ago and 42% ≥4 years ago. Regarding disease stage, 68% of women had localised breast cancer, 5% locally advanced disease, 22% metastatic disease, and 5% were not aware of their disease stage. Socio-demographic characterisation and disease stage of the study population is further detailed in Table 1. 

1.3 Commuting and hospital waiting times 
The main mode of transportation to and from the hospital for treatment purposes was patients’ own vehicle (42%), with 21% of patients depending on ambulance transportation and 15% on public transports (Table 2). 

The total commuting time to and from the hospital was highly variable, with patients spending between 10 minutes to 2 hours in the process (Figure 2). Within the hospital, time spent waiting for treatment start was also variable, with 56% of patients reporting waiting less than 60 minutes and 26% less than 20 minutes (Figure 2).

Time spent on treatment was the most variable parameter, in agreement with the high diversity of treatments used in breast cancer (Figure 2). Patient commuting times and hospital waiting times are presented in Table 3. 

Most women (63%) were accompanied while going to treatment, 47% by their partners (Table 4). About 1 in every 3 women went to treatment alone.