Editing Patient Pathways: Breast Cancer

<span id="breast-cancer"></span>
= Breast cancer =

Breast cancer is the second leading cause of cancer death and the most common malignant tumor in women worldwide, as well as in Croatia, and most commonly affects women aged 60 to 75. It occurs when cells in the breast begin to divide uncontrollably, creating a tumor that can be benign (non-cancerous) or malignant (cancerous). It most often develops in the ducts that carry milk to the nipple (ductal carcinoma) or in the glands that produce milk (lobular carcinoma). Although breast cancer is most commonly associated with women, it can also occur in men, but much less frequently. Due to the complexity of treatment and various therapeutic options that include surgery, radiotherapy, chemotherapy, targeted therapy, and hormone therapy, breast cancer patients face numerous challenges. Therefore, it is essential to provide comprehensive support measures that include medical care, psychological support, and education to improve patients’ quality of life and facilitate coping with the disease.

Breast cancer is divided into five categories: Carcinoma in situ, Early invasive carcinoma, Locally advanced carcinoma, Regionally advanced carcinoma, and Metastatic carcinoma. About 5-10% of breast cancer cases have a family history (genetic predisposition). Then the disease usually occurs at a younger age, and there are frequent cases of bilateral breast cancer. In this case, it is usually a matter of more aggressive subtypes of the disease, with a worse course and prognosis. The best-known hereditary breast cancer is the one related to mutations in the BRCA1 and BRCA2 genes. For women who carry the BRCA gene mutation, the risk of developing breast cancer during their lifetime is as high as 90%.

<span id="patient-pathways"></span>
= Patient pathways =

Creating a comprehensive plan for breast cancer treatment includes steps from initial presentation and diagnosis to treatment and follow-up. Below is a detailed plan:

<span id="diagnostics"></span>
== 1. Diagnostics ==

A patient presents with symptoms such as a lump in the breast, a change in the size or shape of the breast, nipple discharge, swelling or a lump in the armpit, persistent breast pain or discomfort, redness, and hardening of the skin.

Consultation with a general practitioner (GP): The patient sees a general practitioner or gynecologist.

Medical history and physical examination: Detailed patient history.

'''Initial tests:''' clinical breast examination.

'''Referral to a specialist'''

Referral to a radiologist.

'''Diagnostic evaluation'''

'''Diagnostic Mammography:''' Provides a more detailed X-ray of the breast.

'''Ultrasound:''' For further evaluation of abnormalities, particularly useful for women with dense breast tissue where mammography may be less effective.

'''MRI:''' Used for high-risk patients.

'''Biopsy:''' When breast cancer is suspected, a biopsy of the breast tumor is required before any treatment is planned.

'''Chest X-ray:''' Checks for the spread of cancer to the lungs.

'''CT Scan:''' Detailed images of the chest, abdomen, and pelvis to check for metastases.

'''Bone Scan:''' Detects the spread of cancer to the bones.

'''PET-CT:''' Combines PET and CT scans for detailed images and metabolic activity of tissues.

'''Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection:''' Evaluates the spread of cancer to the lymph nodes, key for determining the stage and planning treatment.

<span id="treatment"></span>
== 2. Treatment ==

'''Multidisciplinary Team (MDT) meeting'''

'''MDT discussion:''' Review of diagnostic findings with specialists including endocrinologists, surgeons, oncologists, radiologists, and pathologists.

'''Treatment plan development:''' Based on tumor stage (TNM system), type of breast cancer, and the patient’s general health.

'''Treatment options'''

'''Surgical Treatment:''' The main treatment for most types of breast cancer.

'''Lumpectomy (Breast-Conserving Surgery):''' Removal of the tumor and a small margin of surrounding tissue.

'''Mastectomy:'''

Simple or total mastectomy – the entire breast is removed.

Modified radical mastectomy – the breast and axillary lymph nodes are removed.

Radical mastectomy – the breast, axillary lymph nodes, and chest muscle under the breast are removed.

'''Sentinel Lymph Node Biopsy:''' Checks for the involvement of lymph nodes

'''Radiotherapy'''

'''Systemic Therapy'''

'''Hormone Therapy:''' This is the most important type of systemic treatment for ER-positive tumors, which are also called hormone-dependent tumors.

'''Chemotherapy:''' This therapy destroys cancer cells and is mostly used for triple-negative, HER2-positive, and luminal B breast cancer.

'''Targeted Therapy:''' Targeted treatments are drugs that block certain signaling pathways in cancer cells that encourage them to grow.

<span id="post-treatment-follow-up-rehabilitation-and-survivorship"></span>
== 3. Post-Treatment: Follow-Up, Rehabilitation, and Survivorship ==

Regular check-ups are recommended every 3 months for the first 3 years after treatment (every 6 months for low-risk EBC), every 6 months from year 4 to 5, and annually thereafter.

Annual bilateral (after BCT) or contralateral mammography (after mastectomy) plus ultrasound and breast MRI, when needed.

Participation in national screening programs for other types of cancer.

For asymptomatic patients, laboratory tests (e.g., blood counts, blood chemistry, tumor marker assessment) or other imaging tests are not recommended.

Regular bone density assessment for patients on aromatase inhibitors (AIs) or who have undergone OFS.

<span id="palliative-care-if-applicable"></span>
== 4. Palliative Care (If Applicable) ==

'''Hospice care:''' specialized type of palliative care provided to patients with terminal illnesses.

'''Pain management and control'''

'''Medications:''' Analgesics, opioids, antidepressants, and anticonvulsants.

'''Physical methods:''' Massage, physiotherapy, and acupuncture.

'''Psychological methods:''' Cognitive-behavioral therapy, mindfulness, and relaxation techniques.

'''Palliative Treatments'''

Symptom control, nutritional support, psychosocial and spiritual support.

<span id="challenges-breast-cancer-patients-face-during-their-treatment-journey"></span>
= Challenges breast cancer patients face during their treatment journey =

<span id="challenges-during-diagnostic-evaluation"></span>
== Challenges during diagnostic evaluation ==

A breast cancer diagnosis can be a stressful and challenging time for patients. Support during this phase can significantly improve the patient’s emotional and physical well-being.

Breast cancer patients face various difficulties during diagnosis, such as physical, psychological, financial and professional difficulties, and lack of information.

'''Physical Challenges'''

'''ymptoms of the disease:''' Lump in the breast, change in the size or shape of the breast, nipple discharge, pain and discomfort during biopsy.

'''Psychological Challenges'''

Fear of a cancer diagnosis, uncertainty about treatment: fear of possible complications and side effects of treatment. The process of emotionally accepting a cancer diagnosis can be very stressful and challenging. The patient needs emotional support, which puts pressure on family and friends to provide support.

'''Social isolation:''' feeling isolated because of the illness and need for privacy.

'''Financial and Professional Challenges'''

Absence from work: frequent medical checkups and treatments can cause absence from work, which can affect careers and financial stability. Costs of diagnosis and treatment, insufficient health insurance.

'''Lack of Information'''

Patients often have difficulty finding reliable and understandable information about their illness, diagnostic procedures, treatment options, and their rights.

'''Insufficiently clear communication with doctors:''' the complexity of medical terminology and lack of time during consultations can make it difficult to fully understand the diagnosis and treatment options.

<span id="challenges-during-treatment"></span>
== Challenges during treatment ==

'''Physical Challenges'''

Arthralgia, myalgia, Bone loss, heart dysfunction, chronic hair loss and thinning, dry mucous membranes (oral, genital, conjunctival), nutritional problems (eg, weight gain), secondary hematological malignancies (or other secondary cancers).

'''Nutritional problems:''' Difficulty eating due to nausea, loss of appetite or difficulty swallowing.

'''Weight changes:''' weight gain or loss due to hormonal changes.

Scars from surgical procedures can affect appearance and self-confidence.

'''Cardiovascular problems:''' hormonal imbalances can affect the heart.

'''Hair loss:''' may occur due to radiotherapy or chemotherapy.

'''Skin problems:''' dry skin, itching or rash due to therapy.

'''Eye problems:''' Dry eyes or irritation due to radiation therapy.

'''Metabolic problems:''' changes in metabolism due to hormone therapy.

'''Psychological Challenges'''

'''Fear and anxiety:''' fear of the disease, treatment, side effects, and uncertainty of outcome, anxiety related to regular check-ups and fear of recurrence.

'''Depression:''' feelings of hopelessness, loss of interest in everyday activities, isolation.

'''Changes in body image:''' discomfort due to physical changes, such as scars or weight changes.

'''Treatment-related stress:''' Psychological stress due to intensive treatments and their impact on everyday life.

'''Relationship with partner:''' sexual problems, decreased libido, and emotional distance due to illness.

'''Family relationships:''' tensions within the family due to stress, changes in roles and responsibilities.

'''Social Isolation:''' withdrawal from social activities due to fatigue, discomfort, or fear of exposure to infections during therapy.

'''Financial and Professional Challenges'''

Reduced ability to work due to fatigue, side effects of treatment, and emotional problems.

'''Absences from work:''' frequent medical visits and treatments that require absences from work, which can affect career and financial stability.

High costs of medicines, surgeries, therapies and other medical services, travel and accommodation costs for patients who have to travel to health centers.

Reduced income due to reduced work capacity or job loss.

Ongoing costs associated with long-term follow-up and maintaining health.

'''Lack of information'''

Need to understand complex medical information and make informed decisions.

Difficulties in making treatment decisions due to lack of reliable and understandable information or conflicting advice.

Unawareness of patient rights.

Lack of information about healthcare providers during treatment.

<span id="challenges-during-rehabilitation-and-disease-monitoring"></span>
== Challenges during rehabilitation and disease monitoring ==

'''Physical Challenges'''

Postoperative pain and cosmetic problems due to scars. Arthralgia, myalgia.

'''Psychological Challenges'''

'''Fear of recurrence:''' persistent fear of the cancer coming back.

'''Anxiety and depression:''' psychological stress and emotional problems related to the experience of cancer.

'''Social isolation:''' reduced social interaction due to fatigue, anxiety or other symptoms.

'''Financial and professional challenges'''

'''Returning to work:''' difficulties returning to work due to physical and emotional limitations.

Long-term financial burden associated with ongoing medical expenses.

<span id="challenges-during-palliative-care"></span>
== Challenges during palliative care ==

Difficulties faced by breast cancer patients in Croatia and their families during palliative care are numerous and include several key aspects:

Limited access to palliative care: there is a significant gap between the need for palliative care and available resources. Insufficient capacities of specialized palliative care providers.

'''Psychological Challenges'''

The psychosocial and emotional burden on patients and their families is often great. Family caregivers often face high levels of stress and emotional burden.

'''Cultural and ethical issues:''' reluctance to discuss end-of-life issues can hinder the provision of effective palliative care. Ethical challenges in decision-making and care provision can also create additional stress for families and healthcare professionals.

'''Financial Challenges'''

Costs of care can be a significant burden for families, especially given the long-term nature of palliative care. The economic pressure can further exacerbate the stress experienced by patients and their families, affecting their overall well-being and quality of life.

Challenges in care coordination: effective palliative care requires coordination among different healthcare providers. In Croatia, there are challenges related to care coordination between hospitals, palliative care units, and home care services. Addressing these challenges requires a comprehensive approach that includes improving access to palliative care, providing emotional and psychological support to families, addressing financial burdens, and ensuring effective care coordination. In addition, public education and awareness raising about the benefits of palliative care can help reduce cultural and ethical barriers.

<span id="challenges-patients-face-after-completing-breast-cancer-treatment"></span>
== Challenges patients face after completing breast cancer treatment ==

'''Physical challenges'''

Loss of bone density, heart dysfunction, chronic hair loss and thinning, dry mucous membranes (oral, genital, conjunctiva), nutritional problems (e.g., weight gain), secondary hematological malignancies (or other secondary cancers). Problems with the musculoskeletal and connective tissue system.

'''Psychological Challenges'''

Cancer survivors often experience anxiety and fear of the cancer returning, which can affect their emotional well-being. They may also face difficulties adjusting after treatment, including changes in daily routines and life plans. The role of family members as caregivers often changes after treatment is complete. Their support remains crucial, but may need to be adapted to the new circumstances and the reduced intensity of care.

'''Lifestyle and prevention:''' patients are encouraged to adopt healthy lifestyle habits such as regular exercise, a healthy diet, not smoking and stress management in order to improve their quality of life and reduce the risk of cancer recurrence.

'''Financial and Professional Challenges'''

'''Return to work:''' many survivors face challenges returning to work, including fatigue, decreased energy, and physical limitations after treatment. They need support in adapting to the work environment and managing employer expectations. Employers are often unaware of how to support cancer survivors upon returning to work.

'''Healthcare Coordination'''

'''Regular check-ups:''' It is important to continue with regular check-ups to monitor for cancer recurrence or side effects of treatment. This includes blood tests and scans, such as ultrasounds, depending on the risk of the cancer recurring.

Breast cancer patients face various challenges during their diagnostic, therapeutic, and rehabilitation journey, including physical, psychological, financial, and professional difficulties, lack of information, and coordinating healthcare.

Providing comprehensive support that includes medical care, psychological support, education and social services can significantly improve the quality of life and treatment outcomes for these patients.

<span id="supportive-activities-for-patients-diagnosed-with-breast-cancer"></span>
= Supportive activities for patients diagnosed with breast cancer =

A coordinated multidisciplinary approach to providing supportive care in healthcare settings is essential to help patients throughout their treatment journey. Such an approach significantly improves the quality of life of breast cancer patients, helping them cope with the difficulties that the disease and treatment bring. Civil society organizations, such as patient associations and cancer advocacy groups, can play a key role in informing patients about such supportive activities. Also, with the help of experts, associations can organize and provide some of the necessary support to patients in order to reduce physical, psychological, financial and professional difficulties, lack of verified and understandable information, and strengthening healthcare coordination, not only within the health system but also through activities aimed at actively involving patients in the development of better national health guidelines and policies.

<span id="supportive-activities-provided-by-healthcare-institutions"></span>
== Supportive Activities Provided by Healthcare Institutions ==

Supportive activities for breast cancer patients within the healthcare system encompass a wide range of services aimed at improving the overall quality of life for patients. In addition to healthcare, which includes regular monitoring through blood tests, ultrasound, MRI or CT scans, and follow-up by specialist physicians, for optimal management of physical difficulties, patients should have access to a multidisciplinary team of experts.

'''Endocrinologist:''' Management of hormonal imbalances and metabolic problems.

'''Oncologist:''' Overall cancer management.

'''Nutritionist:''' Diet counseling and weight management.

'''Surgeon:''' Surgical treatment of cancer and postoperative care.

'''Physiotherapist:''' Pain management and improved mobility.

'''Pain specialist:''' Postoperative pain control.

'''Plastic surgeon:''' Cosmetic procedures and scar management.

'''Dermatologist:''' Skin problems and hair loss.

'''Cardiologist:''' Monitoring and treatment of cardiovascular problems.

'''Ophthalmologist:''' Eye problems related to therapy.

'''Supportive Activities for Psychological Challenges'''

Patients diagnosed with cancer and their families almost inevitably face numerous psychological difficulties throughout the entire therapeutic journey. Professional psychological help in the form of individual counseling, group therapy, counseling with a partner, and family counseling is a key part of support for oncology patients. Also, a psychiatrist may recommend psychopharmacotherapy as a support for patients.

'''Supportive activities for providing reliable and understandable information'''

'''Informed Consent:''' The signed form is proof that the conversation in which the doctor provides information to the patient about diagnostic and therapeutic procedures, risks, complications, and alternative treatments has led to mutual understanding. Detailed but easy-to-understand educational materials for patients are essential in this process, but often unavailable.

'''Right to a Second Medical Opinion:''' Guaranteed by the Patient Rights Act. The patient always has the right to seek a second medical opinion about their health status. Upon oral or written request, every healthcare professional of higher education and appropriate specialization who was not involved in the direct provision of a certain type of healthcare service to the patient is obliged to give a second medical opinion to the patient. In addition to the patient, the doctor can also initiate the procedure of seeking a second opinion. In the case of diagnosing a rare disease, the inability to find (adequate) therapy, technological equipment of the health institution that makes it impossible or difficult to establish a diagnosis or the course of therapy, doctors often seek help and confirmation from their colleagues from other institutions for the purpose of the highest quality approach to each patient.

<span id="supportive-activities-provided-by-associations"></span>
== Supportive activities provided by associations ==

'''Supportive activities for physical challenges'''

Support related to side effects of treatment: organizing workshops and informative activities that educate patients on ways to manage side effects. Providing brochures and online resources with practical tips.

Support related to symptoms of the disease: access to medical professionals for early intervention and treatment of symptoms.

Organizing counseling centers where patients can receive advice from medical professionals and psychologists. Inclusion of medical advisors in support programs.

Support related to metabolic disorders, eating problems and lack of energy: connecting patients with nutritionists and endocrinologists through organized events and online consultations for the personalization of the patient’s diet plan and collaboration of fitness and nutrition experts for personalized recommendations for moderate exercise. Organizing practical workshops for proper nutrition, creating educational materials.

'''Supportive activities for psychological challenges'''

Offering free or subsidized psychological counseling, organizing support groups, and telephone lines for psychological support.

For depressive disorders, support in finding a psychiatrist and therapist, and cooperation between associations and them. Organizing support groups for conversation and sharing experiences.

Organizing workshops and therapy groups that focus on body positivity and accepting change. Providing free courses in meditation, yoga, and relaxation techniques. Creating online resources and applications to support stress management.

Associations can organize workshops for couples, including counseling with sexual health professionals. Organizing family therapy sessions and workshops that include all family members in the support process. Connecting with peer groups and social activities. Organizing social events, online forums, and support groups where patients can connect and share their experiences.

'''Supportive activities for financial and professional challenges'''

Advice on labor rights and workplace adaptation. Providing legal advice and support for talking to employers about adapting the workplace. Organizing workshops on worker rights.

Connecting patients with financial advisors and organizing workshops on managing finances during treatment. Providing information about financial aid, organizing fundraising campaigns, and assistance in applying for financial aid. Connecting patients with social workers and providing free financial advice.

'''Supportive activities for providing reliable and understandable information necessary for informed participation in the treatment process'''

Understanding the disease and treatment: education and informational materials.

Organizing educational seminars and workshops with medical professionals.

Distribution of brochures and online resources about the disease and treatment.

'''Supportive activities for patient rights'''

Providing information on rights and social assistance options. You can find everything about patient rights at this link of the IGET association - Institute for Gastroenterological Tumors: https://iget.hr/prava-osoba-oboljelih-od-onkoloskih-bolesti/.

<span id="examples-of-successful-supportive-activities-of-croatian-associations"></span>
= Examples of successful supportive activities of croatian associations =

Civil society organizations, patient associations play a vital role in providing support to breast cancer patients. These groups often offer peer support systems where patients can connect with others going through similar experiences, providing a sense of community and mutual understanding. They can also organize educational workshops and seminars to inform and educate patients to empower them to actively participate in the treatment process.

Patient associations are also active in health and social care system policies by raising awareness among the public and political stakeholders about the needs of patients, and about their rights.

There is a large number of civil society organizations operating in Croatia that provide support to cancer patients. The directory lists a larger number of associations in Croatia, while here we highlight a few:

'''Europa Donna Hrvatska'''

Address: Kneza Mislava 7, Zagreb

Contact: 01 4840 955

Web: europadonna.hr

'''Sve za nju'''

Address: Ljudevita Posavskog 1, Zagreb

Contact: 01 4666 900

Web: svezanju.hr

'''Nismo Same'''

Address: Boškovićeva ulica 7b, Zagreb

Contact: 097 7561 683

Web: nismosame.hr

'''Udruga Mammae klub Varaždin'''

Address: Graberje 33, 42000 Varaždin

Phone: 042/206-900

Web: https://rakdojke.com/

'''Udruga Mammae Osijek'''

Address: J. Leovića 4 (Dom zdravlja “Drava”), 31000 Osijek

Phone: 031 373366, 091/480-1102

Web: https://mammae-klub-osijek.hr/

'''Liga protiv raka Pula'''

Address: Nobileova 1, 52100 Pula

Phone: 052 222 795

Web: https://www.ilco.hr/index.php/drustva/pula

'''EUROPA DONNA HRVATSKA'''

Address: Veslačka 12, 23000 Zadar

Phone: +385 23 627 783

Web: https://ligaprotivrakazadar.hr/

'''Županijska Liga protiv raka - Split'''

Address: Spinčićeva 1, 21000 Split

Phone: 021 556 476 -

Web: https://www.zlpr.hr/liga/

'''Udruga Nada Rijeka'''

Address: Milana Smokvine Tvrdog 5/1, 51 000 Rijeka

Phone: 051 371 062, 097 613 9715

Web: https://klub-nada-rijeka.hr/

'''Liga protiv raka Šibeniko-kninske županije'''

Address: Trg Nikole Tomasea 2, 22000 Šibenik

Phone: 022 218993

Facebook - Liga protiv raka Šibeniko-kninske županije

'''Udruga Županijska liga protiv raka - Čakovec'''

Address: A. Schulteissa 19, 40000 Čakovec

Web: https://www.zlprck.hr/

'''Liga protiv raka Vinkovci'''

Address: Trg bana Josipa Šokčevića 1, 32100 Vinkovci

Facebook - Liga protiv raka Vinkovci

'''Udruga Krijesnica'''

Address: Prilaz Gjure Dežalića 50, 10000 Zagreb

Phone: +385 1 3770 477

Web: https://krijesnica.hr/

'''Koalicija udruga u zdravstvu (KUZ)'''

Address: Trpimirova 11, 10000 Zagreb

Phone: +385 1 4572 100

Web: https://www.kuz.hr/

'''Hrvatska udruga za promicanje prava pacijenata'''

Address: Zrinsko Frankopanska 2b, 21000 Split

Phone: +385 915027861

Web: https://pravapacijenata.hr/

<span id="available-support-content-for-cancer-patients"></span>
= Available support content for cancer patients =

The Croatian translation of several Patient Guides was carried out by the Association of Women Diagnosed and Treated for Cancer ALL for HER, based on the approval of the European Society for Medical Oncology (ESMO).

'''ESMO Patient Guide Living with Cancer'''

This Living with Cancer Patient Guide was compiled by the European Society for Medical Oncology (ESMO) and the European Cancer Patient Coalition (ECPC) in collaboration with the International Psycho-Oncology Society (IPOS) to help you and those like you at this important time in your life. In this Guide, you can find information about support in coping with the new reality of life, life after primary treatment, preventive care, and long-term follow-up. It will also help you keep a personal health record, i.e. plan your healthcare throughout your life with cancer.

The Guide was translated by Dea Ajduković, PhD, and the translation was reviewed by Natalija Dedić Plavetić, PhD, Marko Jakopović, MD, PhD, and on behalf of patients by psychologist Ljiljana Vukota from the ALL for HER association.

https://www.esmo.org/content/download/131276/2458900/1/ESMO-Vodic-za-Bolesnike-Zivot-s-Rakom.pdf

'''ESMO Personalised Medicine in Oncology: A Guide for Patients'''

This patient guide was initiated by the ESMO Personalised Medicine Working Group to help patients, their families, and friends better understand the factors that can influence a personalised approach to cancer prevention, diagnosis, and treatment. This brochure presents current knowledge about the basic principles of personalized medicine, illustrating its application to several types of tumors. Personalised medicine is the future of cancer treatment, and for it to become a reality in the near future and enable better cancer therapy, the role of patients is crucial. In this expanding and evolving approach, ESMO is committed to educating patients so they can better understand its key principles and their own contribution to advancing treatment.

The Croatian translation of the Guide was made possible by the Association of Women Diagnosed with and Treated for Cancer ALL for HER based on the approval of the European Society for Medical Oncology (ESMO). The text of the Croatian translation was reviewed by: Prof. Ljiljana Šerman, Prof. Floriana Bulić-Jakuš and Ms. Ljiljana Vukota.

https://www.esmo.org/content/download/385655/7486427/1/HR-Personalizirana-Medicina-u-Onkologiji-Vodic-za-Bolesnike.pdf

'''ESMO Side Effects Associated with Immunotherapy and their Management: A Guide for Patients'''

This guide has been prepared to help you and your family, friends, and caregivers better understand immunotherapy-related side effects and their management. It provides information on the most common toxicities associated with modern immunotherapies (known as “immune checkpoint inhibitors”), how your oncology team can manage those symptoms, and a few approaches you can take yourself to help reduce their impact. The medical information described in this document is based on the ESMO Clinical Practice Guidelines for the Management of Immunotherapy Toxicities, which are designed to support clinicians in diagnosing, treating, and monitoring these events. All ESMO Clinical Practice Guidelines are developed and reviewed by leading experts, using evidence from the latest clinical trials, scientific research, and expert opinion.

The Croatian translation of the guide was reviewed by: representative of the Croatian Society for Internal Oncology: Natalija Dedić Plavetić, MD, PhD, representative of the Croatian Thoracic Society: Marko Jakopović, MD, PhD, representative of the Association of Women Diagnosed with and Treated for Cancer ALL for HER: Ljiljana Vukota.

'''ESMO Cancer Treatment During the Covid-19 Pandemic: A Guide for Patients'''

The Guide contains information about the COVID-19 disease and its symptoms, as well as measures you can take to reduce the risk of infection. Also, the guide provides information about the impact of the COVID-19 pandemic on various aspects of cancer treatment, including possible changes to your treatment plan and medical examinations that may be needed to protect you from infection.

The Croatian translation was reviewed by: Paula Podolski, MD, PhD, president of the Croatian Senological Society, Borislav Belev, MD, PhD, medical oncologist, National representative of the Croatian Society for Internal Oncology at ESMO and Ljiljana Vukota, representative of the ALL for HER association.

http://www.svezanju.hr/lijecenje-raka-tijekom-pandemije-covid-19-esmo-vodic-za-bolesnike/

'''ESPEN practical guideline: Clinical Nutrition in cancer'''

Malnutrition is a common feature in cancer patients and is a consequence of the presence of a tumor and of medical and surgical anticancer treatments. Malnutrition negatively affects quality of life and treatment toxicity, and it is estimated that up to 10–20% of patients with cancer die from the consequences of malnutrition rather than the tumor itself. As such, nutrition plays a key role in multimodality cancer care. Strong evidence demonstrates that nutritional issues should be considered from the time of cancer diagnosis, within the diagnostic and therapeutic pathway, and should run in parallel with antineoplastic treatment. However, worldwide, cancer-associated malnutrition remains largely unrecognised, underestimated and undertreated in clinical practice. These evidence-based guidelines have been developed to translate the current best evidence and expert consensus into recommendations for multidisciplinary teams responsible for identifying, preventing and managing reversible elements of malnutrition in adult patients with cancer.

<span id="directory-of-associations-offering-supportive-activities-to-cancer-patients"></span>
= Directory of associations offering supportive activities to cancer patients =

<span id="zagreb"></span>
== Zagreb ==

'''Croatian League Against Cancer'''

Offer: Psychological support, support groups, education, financial aid.

Contact:

Address: Ilica 197, 10000 Zagreb

Phone: +385 1 3775 572, 099 5361 386

Email: info@hlpr.hr

Web: https://www.hlpr.hr

'''Association Institute for Gastroenterological Tumors (Iget)'''

Activities: Counseling, education, campaigns to promote healthy lifestyle habits,

connecting patient associations and medical professionals, developing informative content for patients

Contact:

Address: Ilica 197, 10000 Zagreb

Phone: +385 955578 587

Email: info@ iget.hr

Web: https://iget.hr

'''Association ALL for HER'''

Offer: Psychological support, education, information, support groups.

Contact:

Address: Kneza Mislava 10, 10000 Zagreb

Phone: +38516418765

Email: info@svezanju.hr

Web: http://svezanju.hr

'''Coalition of Associations in Healthcare (KUZ)'''

Patient Rights Advocacy: KUZ is dedicated to protecting patient rights and representing their interests before healthcare institutions.

Education: Organizing workshops and lectures on patient rights.

Public Campaigns: Campaigns to raise awareness of patient rights and better access to healthcare.

Counseling: Providing legal and administrative support to patients.

Contact:

Address: Trpimirova 11, 10000 Zagreb

Phone: +385 1 4572 100

Email: President Ivica Belina: ivica.belina50@gmail.com

Web: https://www.kuz.hr/

'''Croatian Society of Prostate Cancer Patients (HDBRP)'''

Activities: Providing psychological support, counseling, and information to patients diagnosed with prostate cancer and their families, organizing lectures, distributing educational materials, and campaigns to raise awareness of prostate cancer prevention and early detection, organizing support groups where patients can share their experiences and receive emotional support, campaigns to raise awareness of prostate cancer and the importance of regular examinations.

Contact:

Address: Ilica 65/1, 10000 Zagreb

Phone: not listed

Email: info@hdbrp.hr

Web: https://www.hdbrp.hr

'''Association for Thyroid Patients'''

Activities: Providing individual and group psychological support to patients diagnosed with thyroid diseases, organizing workshops, lectures, and distributing educational materials on thyroid diseases, counseling and supporting patients in the rehabilitation process after treatment, campaigns to raise awareness of thyroid diseases and the importance of early detection and treatment, Informative platform providing advice on nutrition, treatment and symptom management.

Contact:

Address: Ulica Frane Petrića 5, 10000 Zagreb

Phone: +38513464 723

Email: udruga.stitnjaca@gmail.com

Web: https://stitnjaca.eu/

'''Krijesnica Association'''

Offer: Psychological support, legal aid, financial aid, workshops.

Contact:

Address: Prilaz Gjure Dežalića 50, 10000 Zagreb

Phone: +385 1 3770 477

Email: info@krijesnica.hr

Web: https://krijesnica.hr/

<span id="split-dalmatia-county"></span>
== Split-Dalmatia County ==

'''County League Against Cancer - Split'''

Offer: Education, support groups, psychological help.

Contact:

Address: Spinčićeva 1, 21000 Split

Phone: 021 556 476

Email: office@zlpr.hr

Web: https://www.zlpr.hr/liga/

'''Croatian Association for the Promotion of Patient Rights'''

Activities: advising on patient rights and assisting in accessing healthcare services, education and information

Contact:

Address: Zrinsko Frankopanska 2b, 21000 Split

Phone: +385915027861

Email: info@pravapacijenata.hr

Web: https://pravapacijenata.hr/

<span id="primorje-gorski-kotar-county"></span>
== Primorje-Gorski Kotar County ==

'''Nada Rijeka Association'''

Offer: Psychological support, education, workshops.

Contact:

Address: Milana Smokvine Tvrdog 5/1, 51 000 Rijeka

Phone: 051 371 062, 097 613 9715

Email: klub.nada.rijeka@gmail.com

Web: https://klub-nada-rijeka.hr/

<span id="osijek-baranja-county"></span>
== Osijek-Baranja County ==

'''Mammae Osijek Association'''

Offer: Psychological support, information, support groups.

Contact:

Address: J. Leovića 4 (Dom zdravlja “Drava”), 31000 Osijek

Phone: 031 373366, 091/480-1102

Email: klubmammaeos@gmail.com

Web: https://mammae-klub-osijek.hr/

<span id="istria-county"></span>
== Istria County ==

'''League Against Cancer Pula, Stoma Club Pula'''

Offer: Education, support for patients, information.

Contact:

Address: Nobileova 1, 52100 Pula

Phone: 052 222 795

Email: liga.protiv.raka@pu.t-com.hr

Web: https://www.ilco.hr/index.php/drustva/pula

<span id="zadar-county"></span>
== Zadar County ==

'''League Against Cancer Zadar'''

Offer: Psychological support, education, information.

Contact:

Address: Veslačka 12, 23000 Zadar

Phone: +38523627 783

Email: info@ligaprotivrakazadar.hr

Web: https://ligaprotivrakazadar.hr/

<span id="šibenik-knin-county"></span>
== Šibenik-Knin County ==

'''League Against Cancer Šibenik-Knin County'''

Offer: Education, support groups, psychological help.

Contact:

Address: Trg Nikole Tomasea 2, 2000 Šibenik

Phone: 022 218993

Email: liga.sibenik@gmail.com

Find them on Facebook Liga protiv raka Šibeniko-kninske županije

<span id="varaždin-county"></span>
== Varaždin County ==

'''Association Mammae klub Varaždin'''

Offer: Psychological support, education, workshops.

Contact:

Address: Graberje 33, 42000 Varaždin

Phone: 042/206-900

Email: mammae.klub.varazdin@ vz.t-com.hr

Web: https://rakdojke.com/

<span id="vukovar-srijem-county"></span>
== Vukovar-Srijem County ==

'''League Against Cancer Vinkovci'''

Offer: Education, support groups, information.

Contact:

Address: Trg bana Josipa Šokčevića 1, 32100 Vinkovci

Find them on Facebook Liga protiv raka Vinkovci

<span id="međimurje-county"></span>
== Međimurje County ==

'''Association County League Against Cancer - Čakovec'''

Offer: Psychological support, education, information.

Contact:

Address: A. Schulteissa 19, 40000 Čakovec

Phone:

Email: liga.protiv.raka.medjimurje@gmail.com

Web: https://www.zlprck.hr/