Editing Patient Pathways: Colon Cancer

<span id="colon-cancer"></span>
= Colon cancer =

Colon cancer (CRC) is the third most common cancer in men and the second most common in women, accounting for 10% of all cancers in the world. The incidence is 25% higher in men and varies greatly between countries. With more than 600,000 deaths estimated each year, CRC is the fourth leading cause of cancer death worldwide. Colon cancer most often develops over a number of years and begins with the growth of polyps, i.e. protrusions on the mucous membrane that represent a benign (benign) tumor. However, some polyps change and begin to grow into the intestinal wall and surrounding tissue and spread to the blood and lymph vessels and lymph nodes - then we are talking about colon cancer. While there are several types of colon cancer (depending on the tissue of the colon from which it originated), the most common is adenocarcinoma, which arises from cells that secrete substances into the lumen of the colon. The most significant risk factors that increase the risk of developing colorectal cancer are: family history of CRC or adenoma, hereditary genetic mutations in familial adenomatous polyposis coli, history of adenoma, colorectal cancer or inflammatory bowel disease (Crohn’s disease and ulcerative colitis) , and FAP mutations of the APC gene. Still, some polyps change and begin to grow into the intestinal wall and surrounding tissue and spread to the blood and lymph vessels and lymph nodes - then we are talking about colon cancer. While there are several types of colon cancer (depending on the tissue of the colon from which it originated), the most common is adenocarcinoma, which arises from cells that secrete substances into the lumen of the colon. Due to the complexity of treatment and the various therapeutic options that include surgery, radiotherapy and hormone therapy, colon cancer patients face numerous challenges. Therefore, it is necessary to provide comprehensive support measures that include medical care, psychological support and education in order to improve the quality of life of patients and facilitate coping with the disease. Colon cancer is divided into four categories: early invasive carcinoma, locally advanced carcinoma, regionally advanced carcinoma, and metastatic carcinoma.

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

Developing a comprehensive plan for the treatment of colon cancer includes steps from initial presentation and diagnosis to treatment and follow-up. Below is a detailed plan:

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

The patient presents with symptoms such as blood in the stool, increased abdominal discomfort, changes in habits - hardness, color or frequency of stools, unexplained weight loss, prolonged fatigue and unexplained weakness of the intestines, general or localized abdominal pain.

'''Consultation with a general practitioner (GP):''' The patient visits a general practitioner. '''Medical history and physical examination:''' Detailed patient history. '''Initial tests:''' colonoscopy and non-invasive tests.

'''Referral to a specialist''' Referral to a radiologist and oncologist.

'''Diagnostic evaluation'''

'''Hemoccult:''' Detects blood in the stool that is not visible to the naked eye - it is used as the basis for screening in Croatia. '''Colonoscopy:''' a method by which the doctor examines the inside of the entire large intestine and during which it is possible to remove smaller polyps and see suspicious formations. Radiological blood tests (CT, NMR, Lung X-ray, PET CT): Gives us information about the local spread of the disease and possible metastases. '''Blood tests:''' CEA, CA 19-9: tumor markers, give us information about the presence of cancer cells '''CKS:''' detects anemia (‘anemia’) which occurs due to bleeding from the tumor into the interior of the intestines '''Genetic tests:''' We use them when the patient is of a younger age or if there is a family history of that or related types of cancer.

<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. Development of a treatment plan: Based on the stage of colon cancer and the patient’s overall health.

'''Treatment options'''

'''Surgery'''

Surgery is the primary treatment for localized colon cancer. For stage III, adjuvant chemotherapy with fluoropyrimidine and oxaliplatin (FOLFOX or CAPOX) is the standard of care.

'''Chemotherapy'''

Adjuvant chemotherapy is recommended for patients with stage III and high-risk stage II. Treatment is usually given for 3 to 6 months, depending on the specific regimen and risk of recurrence.

'''Targeted Therapy'''

Patients with metastatic colorectal cancer may receive EGFR-directed therapies (if they do not have KRAS/NRAS mutations) or VEGF, as well as BRAF inhibitors for patients with the BRAF V600E mutation.

<span id="after-treatment-follow-up-rehabilitation-and-survival"></span>
== 3. After treatment: follow-up, rehabilitation and survival ==

Monitoring- Intensive care unit, regular check-ups with physical examinations

Periodic imaging tests (ultrasound, CT or MRI) to monitor for recurrence.

Rehabilitation- Physical therapy to recover from surgery.

'''Psychosocial support:''' counseling and support groups for emotional well-being.

'''Long-term care for survivors:''' monitoring for late effects of treatment. Promoting health and lifestyle changes to improve overall well-being. Secondary prevention: screening for other malignancies and maintaining a healthy lifestyle.

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

'''Palliative treatments:''' To relieve symptoms and improve quality of life in advanced cancer.

'''Pain management:''' Medications, nerve blocks.

'''Symptom control:''' Managing shortness of breath, pain, etc.

'''Hospice care:''' For end-of-life care when curative treatment is no longer an option.

<span id="challenges-faced-by-colon-cancer-patients-during-their-treatment-journey"></span>
= Challenges faced by colon cancer patients during their treatment journey =

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

Diagnosis of colon cancer can be a stressful and challenging time for patients. Support during this phase can significantly improve the patient’s emotional and physical condition. Patients with colon cancer face various difficulties during diagnosis, such as physical, psychological, financial and professional difficulties and lack of information.

'''Physical difficulties'''

'''Symptoms of the disease:''' blood in the stool is the first symptom of colon cancer, which can cause discomfort and anxiety. In addition, there may be discomfort during colonoscopy, prolonged fatigue and unexplained weight loss.

'''Psychological difficulties'''

Fear of cancer diagnosis, uncertainty about treatment: fear of possible complications and side effects of treatment. The process of emotional acceptance of 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:''' the feeling of isolation due to illness and the need for privacy.

'''Financial and professional difficulties'''

'''Absence from work:''' frequent medical examinations and treatments can cause absence from work, which can affect career and financial stability. The costs of diagnosis and treatment, insufficient health insurance.

'''Lack of information'''

Patients often have difficulty finding reliable and understandable information about the disease, 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 difficulties'''

'''Lack of energy:''' constant fatigue and exhaustion due to treatment and hormonal

Bleeding during surgery, the appearance of infection in the wound area, non-healing of the wound (dehiscence), damage to the nerves of the small pelvis, which leads to difficulties with urination, stool or erectile function.

Scars from surgery can affect appearance and self-confidence.

'''Cardiovascular problems:''' hormonal imbalance can affect the work of the heart.

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

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

'''Eye problems:''' Dry eyes or irritation from radiotherapy.

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

'''Changes in weight:''' weight gain or loss due to hormonal changes.

'''Psychological difficulties'''

'''Fear and anxiety:''' fear of illness, 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 changes in weight.

'''Stress due to treatment:''' Psychological stress due to intensive treatments and their impact on everyday life.

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

'''Family Relationships:''' Tensions within the family due to stress, role changes and responsibilities.

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

'''Financial and professional difficulties'''

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

'''Absence from work:''' frequent medical appointments and treatments that require absence from work, which can affect career and financial stability.

High costs of medicines, operations, therapies and other medical services, travel and accommodation costs for patients who have to travel to healthcare centers. Reduced income due to reduced work capacity or job loss. Ongoing costs associated with long-term follow-up and health maintenance.

'''Lack of information'''

The 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.

Ignorance 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 difficulties'''

'''Chronic fatigue:''' Feeling exhausted that lasts for weeks or months after the end of treatment.

'''Muscle weakness:''' Reduced muscle strength due to physical inactivity during treatment.

'''Postoperative pain:''' Pain that lasts after surgery.

'''Chronic pain:''' Pain that occurs due to nerve or other tissue damage during treatment.

'''Insomnia:''' Difficulty sleeping, which can be caused by stress, pain, or side effects of treatment.

'''Nightmares and anxiety:''' Problems with emotional stress that affect sleep quality.

'''Swelling:''' Usually in the arms or legs, caused by the removal of lymph nodes or radiation.

'''Psychological difficulties'''

'''Fear of recurrence:''' continued fear of cancer recurrence.

'''Anxiety and depression:''' psychological stress and emotional problems associated with the cancer experience.

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

'''Financial and professional difficulties'''

'''Return to work:''' difficulties in returning to work due to physical and emotional limitations. The long-term financial burden associated with ongoing medical expenses.

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

The difficulties faced by patients with colon cancer in Croatia and their families during palliative care are multifaceted and cover several key aspects: Limited access to palliative care: There is a significant gap between the need for palliative care and available resources. Insufficient capacity of specialized palliative care providers.

'''Psychological challenges''' The psychosocial and emotional burden of patients and their families is often great. Family caregivers often experience high levels of stress and emotional distress. 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 caregiving can also create additional stress for families and healthcare professionals.

'''Financial challenges''' The costs of care can be a significant burden for families, especially considering the long-term nature of palliative care. The financial pressure can further exacerbate the stress experienced by patients and their families, affecting their overall well-being and quality of life. Challenges with care coordination: effective palliative care requires coordination between different healthcare providers. In Croatia, there are challenges related to the coordination of care 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-treatment-for-colon-cancer"></span>
== Challenges patients face after completing treatment for colon cancer ==

'''Physical challenges'''

'''Fatigue:''' It is often present even after treatment is finished. It can be caused by chemotherapy, radiotherapy or the stress of battling cancer.

'''Changes in bowel function:''' Patients may experience long-term changes in bowel movements, including diarrhea, constipation, incontinence, or a feeling of incomplete emptying.

'''Pain and discomfort:''' Pain in the surgical area can last for a long time. Scars, internal scar tissue (adhesions), and postoperative complications can cause discomfort or pain.

'''Nutritional Deficiencies:''' Due to changes in the digestive system, some patients may have problems absorbing nutrients, which can lead to anemia or other nutritional deficiencies.

'''Neuropathy:''' Nerve damage caused by chemotherapy can lead to tingling, pain, or numbness in the hands and feet.

'''Lymphedema:''' If lymph nodes have been removed during surgery, swelling of the extremities may occur.

'''Complications with a stoma:''' If the patient has a colostomy or ileostomy, problems such as skin irritation, infection or difficulty adjusting to life with a stoma may occur.

'''Psychological challenges'''

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

Lifestyle and prevention: patients are encouraged to adopt healthy lifestyle habits such as regular physical activity, a healthy diet, not smoking and stress management in order to improve health.

<span id="financial-and-professional-difficulties"></span>
= Financial and professional difficulties =

'''Returning to work:''' Many survivors face challenges in returning to work, including fatigue, reduced energy, and physical limitations after treatment. They need support in adapting to the work environment and managing employer expectations. Employers are often unsure how to provide support to cancer survivors upon their return to work.

<span id="coordination-of-health-care"></span>
= Coordination of health care =

'''Regular checkups:''' It is important to continue with regular checkups to monitor for cancer recurrence or side effects of treatment. This includes blood tests and imaging scans, such as ultrasound, depending on the risk of the cancer coming back.

Patients with colon cancer face various challenges during their diagnostic, therapeutic and rehabilitation journey, including physical, psychological, financial and professional difficulties, lack of information, and coordination of health care. 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-with-colon-cancer"></span>
= Supportive activities for patients with colon cancer =

A coordinated multidisciplinary approach to providing supportive care in healthcare settings is essential to helping patients throughout their treatment journey. Such an approach significantly improves the quality of life of patients with colon cancer, helping them to cope more easily with the difficulties that the disease and treatment bring.

Civil society organizations, such as patient associations and cancer charities, can play a key role in informing patients about such supportive activities.

Also, associations themselves, with the help of experts, 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 the coordination of health care, 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 physical challenges'''

Supportive activities for patients with colon cancer within the healthcare system cover a wide range of services aimed at improving the overall quality of life of patients. Along with medical care that includes regular monitoring through blood tests, ultrasound, MRI or CT scans, and follow-up by specialist doctors, for optimal management of physical difficulties, patients should have access to a multidisciplinary team of experts.

'''Family Medicine Physician:''' Takes care of everyday health needs during and after treatment.

'''Oncologist:''' overall treatment management.

'''Dietitian:''' counseling on nutrition and weight management.

'''Physiotherapist:''' pain management and mobility improvement.

'''Psychologist:''' Helps with emotional issues.

'''Oncology nurses:''' take care of you before, during and after treatment, provide information about the daily treatment plan and teach you how to use aids.

'''Supportive activities for psychological challenges'''

Patients 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 therapeutic work, counseling with a partner and family counseling is a key part of support for cancer patients. Also, a psychiatrist may recommend psychopharmacotherapy as support for patients.

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

'''Informed consent:''' a 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 and easily understandable educational content for patients are necessary in this process, but are often not available.

'''Right to a second medical opinion:''' guaranteed by the Patient Rights Act. The patient always has the right to seek a second medical opinion on their health condition. Every healthcare professional with a high professional qualification 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 at the patient’s verbal or written request. In addition to the patient, the doctor is also the one who can initiate the procedure of seeking a second opinion. In the case of diagnosing a rare disease, the impossibility of finding (adequate) therapy, and the inadequate technological equipment of the healthcare institution that prevents or makes it difficult to establish a diagnosis or the course of therapy, doctors often seek the help and confirmation of their colleagues from other institutions for the purpose of 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 the symptoms of the disease: access to medical professionals for early intervention and treatment of symptoms. Organization of counseling centers where patients can receive advice from medical professionals and psychologists. Inclusion of medical advisors in support programs.

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

'''Supportive activities for psychological challenges'''

Offering free or subsidized psychological counseling, organizing support groups and telephone lines for psychological support. In case of depressive disorders, support in finding a psychiatrist and therapist, and cooperation of associations with them. Organization of support groups for conversation and exchange of experiences.

Organizing workshops and therapy groups that focus on body positivity and embracing change. Providing free courses in meditation, yoga, and relaxation techniques. Creating online resources and apps 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 adaptation of the workplace. Providing legal advice and support for talking to employers about adapting the workplace. Organization of workshops on workers’ rights.

Connecting patients with financial advisors and organizing workshops on managing finances during treatment.

Providing information about financial support, organizing fundraising campaigns and assistance in applying for financial assistance. Connecting patients with social workers and providing free financial counseling.

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

'''Understanding illness and treatment:''' education and information materials. Organization of educational seminars and workshops with medical professionals. Distribution of brochures and online resources about the disease and treatment.

'''Supportive activities on patient rights'''

Information is provided about 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 and patient associations play a vital role in providing support to patients with colon cancer. These groups often offer a peer support system where patients can connect with others going through similar experiences, providing a sense of community and 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.

A large number of civil society organizations operate in Croatia, providing support to cancer patients. The directory lists a larger number of associations in Croatia, while here are a few:

'''Croatian League Against Cancer'''

Address: Ilica 197, 10000 Zagreb, Croatia

Telephone: +385 1 3771 428

Email: liga.protiv.raka@poliklinika-breyer.hr

Web page: www.hrvatska-liga-protiv-raka.hr

'''Cro-ILCO'''

Address: Draškovićeva 35, 10000 Zagreb, Croatia

Telephone: +385 1 4923603

Email: croilco@net.hr

Web page: www.croilco.hr

'''We are not alone'''

Address: Boškovićeva ulica 7b, Zagreb

Contact: 097 7561 683

Web: nismosame.hr

'''Institute for Gastroenterological Tumors (IGET)'''

Address: Clinic for Tumors, Ilica 197, 10000 Zagreb, Croatia

Telephone: +385 1 3786444

Email: info@iget.hr

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

The Croatian translation of several Guides for patients was carried out by the Association of Women with and Treated for Cancer SVE za NJU based on the approval of the European Society for Medical Oncology (ESMO).

'''ESMO Guide for Patients Living with Cancer'''

This Patient Guide to Living with Cancer has been produced 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 others like you in this important part of your life.

In this Guide you can find information about support in coping with the new life reality, life after primary treatment, preventive care and long-term follow-up. It will also help you to keep your own health record, i.e. to plan your health care during your life with cancer.

The guide was translated by Dr. sc. Dea Ajduković, and the translation was reviewed by Doc. Dr. sc. Natalija Dedić Plavetić, MD. specialist. int. oncology and on behalf of patients, psychologist Ljiljana Vukota from the SVE za NJU association.

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

'''ESMO Personalized Medicine in Oncology: A Patient Guide'''

This patient guide was launched by the ESMO Personalized Medicine Working Group to help patients, family members, and friends better understand the factors that may influence a personalized approach to cancer prevention, diagnosis, and treatment. This brochure presents current knowledge about the basic principles of personalized medicine, illustrating its application in several types of tumors. Personalized medicine is the future of cancer treatment, and for it to become a reality in the near future and enable better treatment of tumors, the role of patients is crucial.

In this expanding and evolving approach, ESMO is committed to educating patients so that they can better understand its main principles and their own contribution to the advancement of therapy.

The Croatian translation of the Guide was made possible by the Association of Women with and Treated for Cancer SVE za NJU based on the approval of the European Society for Medical Oncology (ESMO). The Croatian translation was reviewed by: Prof. Ljiljana Šerman, prof. Floriana Bulić-Jakuš and Mrs. Ljiljana Vukota.

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

'''ESMO Immune-Related Adverse Events and their Management: A Patient Guide'''

This guide was prepared to help you and your family, friends and caregivers better understand immune-related side effects and their management. It contains information on the most common toxicities associated with modern immunotherapies (known as “immune checkpoint inhibitors”), how your oncology team can manage those symptoms, and some steps you can take yourself to reduce their impact. The medical information described in this document is based on the ESMO Clinical Practice Guidelines for the Management of Immune-Related Toxicities, which are designed to assist clinicians in the diagnosis, treatment and follow-up of these events. All ESMO clinical practice guidelines are prepared 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: a representative of the Croatian Society for Internal Oncology: Doc. Dr. sc. Natalija Dedić Plavetić, representative of the Croatian Thoracic Society: Prof. Dr. sc. Marko Jakopović, representative of the Association of Women with and Treated for Cancer ALL for HER: Ljiljana Vukota.

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

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

The Croatian translation was reviewed by: Prim. Dr. sc. Paula Podolski, president of the Croatian Senological Society, Doc. Dr. sc. Borislav Belev, internist oncologist, National Representative of the Croatian Society for Internal Oncology at ESMO and Ljiljana Vukota, representative of the SVE za NJU 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 the tumor and medical and surgical anti-cancer treatments.

Malnutrition negatively affects quality of life and treatment toxicity, and it is estimated that up to 10-20% of cancer patients die from the consequences of malnutrition, not from the tumor itself. Therefore, nutrition plays a key role in the multimodal treatment of cancer.

Strong evidence shows that nutritional problems should be considered from the time of cancer diagnosis, within the diagnostic and therapeutic pathway, and should run in parallel with anti-cancer treatment. However, worldwide, cancer-related malnutrition is still largely unrecognized, underestimated, and undertreated in clinical practice.

These evidence-based guidelines were developed to translate the current best evidence and expert opinion into recommendations for multidisciplinary teams responsible for identifying, preventing, and managing reversible elements of malnutrition in adult cancer patients.

<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, 0995361 386

Email: info@hlpr.hr

Web: https://www.hlpr.hr

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

Activities: counseling, education, campaigns to promote healthy lifestyles, connecting patient associations and medical professionals, development of informative content for patients

Contact:

Address: Ilica 197, 10000 Zagreb

Phone: +385 955578 587

Email: info@ iget.hr

Web: https://iget.hr

'''Association EVERYTHING 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: Organization of workshops and lectures on patient rights.

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

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 informing patients with prostate cancer and their families, organizing lectures, distributing educational materials, and campaigns to raise awareness of the prevention and early detection of prostate cancer, 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 checkups.

Contact:

Address: Ilica 65/1, 10000 Zagreb

Phone: not listed

Email: info@hdbrp.hr

Web: https://www.hdbrp.hr

'''Association for Patients with Thyroid Diseases'''

Activities: Providing individual and group psychological support to patients 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 , An information platform that provides 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/

'''Association Krijesnica'''

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

Contact:

Address: Prilaz Gjure Dežalić 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 assistance in accessing health 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 ==

'''Association Nada Rijeka'''

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 ==

'''Association Mammae Osijek'''

Offer: Psychological support, information, support groups.

Contact:

Address: J. Leovića 4 (“Drava” Health Center), 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, patient support, information.

Contact:

Address: Nobileova 1, 52100 Pula

Telephone: 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 of Šibenik-Knin County'''

Offer: Education, support groups, psychological help.

Contact:

Address: Trg Nikole Tomasea 2, 22000 Šibenik

Telephone: 022 218993

Email: liga.sibenik@gmail.com

Find them on Facebook League Against Cancer of Šibenik-Knin County

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

'''Association Mammae club Varaždin'''

Offer: Psychological support, education, workshops.

Contact:

Address: Graberje 33, 42000 Varaždin

Telephone: 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 League Against Cancer Vinkovci

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

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

Offer: Psychological support, education, information.

Contact:

Address: A. Schulteiss 19, 40000 Čakovec

Telephone:

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

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