Editing Patient Pathways: Endometrial Cancer

<span id="endometrial-cancer"></span>
= Endometrial cancer =

Endometrial cancer is the most common cancer of the female genital tract in Croatia. According to data from the Croatian Cancer Registry, in 2022, about 1,200 new cases of cancer were recorded endometriosis. This cancer is especially common in women after menopause.

According to the stage, endometrial cancer can be divided into:

Stage 1 - limited to the body of the uterus

Stage 2 - involvement of the cervical stroma, but without spreading beyond the borders of the uterus

Stage 3 - local and / or regional spread of the tumor

Stage 4 - involvement of the bladder and / or lining of the intestine and / or distant metastases.

<span id="cervical-cancer"></span>
= Cervical cancer =

Cervical cancer in Croatia also represents a significant health problem, although the number of new cases have been reduced thanks to screening programs. About 500 new cases were recorded in 2022. The prevalence of this cancer can vary significantly depending on access and effectiveness of screening programs and vaccination against HPV.

According to the stage, cervical cancer can be divided into:

Stage 1 - involvement of the cervix

Stage 2- infiltrated upper part of the vagina and other organs within the pelvis

Stage 3 - all organs within the pelvis are affected, blocked ureter

Stage 4 - the disease has spread to distant organs outside the pelvis

<span id="vaginal-cancer"></span>
= Vaginal cancer =

Vaginal cancer is much rarer in Croatia compared to endometrial and cervical cancer. By available data, there were fewer than 50 new cases in 2022. Due to its rarity, vaginal cancer often presents a challenge in diagnosis and treatment.

According to the stage, vaginal cancer can be divided into:

Stage 1 - disease limited to the walls of the vagina

Stage 2 - the disease has spread to the surrounding tissue, but still only in the area of the pelvis

Stage 3 - all organs and tissues of the pelvis are affected, except for the bladder and rectum

Stage 4 – bladder, rectum and distant organs and tissues are affected (e.g. lungs and bones)

<span id="vulvar-cancer"></span>
= Vulvar cancer =

Vulvar cancer is very rare compared to other types of genital tract cancers. According to data from of the Croatian Cancer Registry and other sources, the prevalence of vulvar cancer in Croatia is low, but important for recognition and treatment. In 2022, less than 50 new cases of vulvar cancer were recorded.

According to the stage, vulvar cancer can be divided into:

Stage 1 - affected tissue of the vulva or perineum

Stage 2 - lower vagina and / or anus involved

Stage 3 - the disease has spread to nearby lymph nodes

Stage 4 - the disease has spread to other organs and tissues and outside the pelvis

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

Developing a comprehensive plan for treating endometrial, vaginal, and vulvar cancers includes steps from initial presentation and diagnosis to treatment and follow-up. Below is a detailed plan:

<span id="diagnosis"></span>
== 1. Diagnosis ==

The patient presents with symptoms such as abdominal pain and bleeding. Vulvar cancer shows discomfort in the vulvar area and frequent itching, in some women with vaginal cancer it is possible watery discharge.

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

'''Medical history and physical examination:''' Detailed medical history of the patient.

'''Initial tests:''' gynecological examination, pap test, HPV testing

'''Referral to a specialist'''

Referral to a radiologist and oncologist

'''Diagnostic evaluation'''

'''Endometrial cancer'''

'''Gynecological examination:''' The doctor performs a physical exam, including a pelvic exam, to evaluate abnormalities in the uterus or other pelvic organs.

'''Transvaginal ultrasound:''' This ultrasound uses high-frequency sound waves to create image of internal structures. It helps to assess the thickness of the endometrium (the lining of the uterus), which can be elevated in case of cancer.

'''Endometrial biopsy:''' Taking a sample of cells from the inner lining of the uterus for analysis under microscope. This is a key test to confirm the diagnosis of endometrial cancer.

'''Hysteroscopy:''' A procedure in which a thin tube with a camera (hysteroscope) is inserted through the vagina and cervix to examine the inside of the uterus and take samples for biopsy.

'''Cervical cancer'''

'''PAPA test (Pap test):''' This test involves taking a sample of cells from the cervix and examining them in the laboratory in order to detect abnormal cells that may indicate cervical cancer or precancerous changes (eg dysplasia).

'''HPV testing:''' Testing for the presence of the human papillomavirus (HPV), which is the main cause cervical cancer. This test can be done alone or in combination with a PAPA test.

'''Colposcopy:''' If the Pap test finds abnormal cells, a colposcopy may be recommended. During this examination, the doctor uses a colposcope (an instrument with magnification) to examine cervix and vagina and may take samples (biopsies) for further analysis.

'''Cervical biopsy:''' Taking a tissue sample from the cervix for analysis to confirm the presence of cancer or other abnormal cells.

'''Vaginal cancer'''

'''Gynecological examination:''' As with other types of cancer, the first step is a physical exam and assessment symptom.

'''Colposcopy:''' Colposcopy is used to examine the vagina and cervix under magnification. If abnormalities are found, biopsies are taken.

'''Vaginal biopsy:''' Taking a tissue sample from the vagina for analysis under a microscope to confirm the presence of cancer.

'''Transvaginal ultrasound:''' This ultrasound can help assess abnormalities in the vagina and surrounding structures.

'''CT scan, MRI, or PET scan:''' These imaging tests can be used to assess the extent disease and determine the spread of cancer to surrounding structures or lymph nodes.

'''Vulvar cancer'''

'''Clinical examination:'''

'''Gynecological examination:''' The doctor performs a physical exam to assess the size, shape, and location tumor and to look for any abnormalities in the area of the vulva, vagina, and cervix.

'''Lymph node palpation:''' Your doctor may feel the lymph nodes in your pelvic and groin area to determine if the cancer has spread to these structures.

'''Colposcopy:''' If abnormalities are found on the vulva, a colposcope (an instrument with magnification) is used to examine the external genitalia and vagina. This exam helps identify abnormal areas that may require further analysis.

'''Biopsy:'''

'''Incisional biopsy:''' Removal of a small portion of the tumor for analysis under a microscope. This procedure allows for histological examination and confirmation of the presence of cancer.

'''Excisional biopsy:''' Removal of the entire tumor and surrounding healthy tissue. This method can serve both therapeutic and diagnostic purposes.

'''Imaging tests:'''

'''CT scan (computed tomography):''' It is used to assess the spread of cancer to the lymph nodes and surrounding structures and for treatment planning.

'''MRI (magnetic resonance imaging):''' Provides detailed images of soft tissues and can help in determining the exact stage of cancer and its spread to surrounding tissues.

'''PET scan (positron emission tomography):''' Used in some cases to detect metastases or spread of disease

'''Lymphangiography:''' In some cases, it is used to visualize the lymph nodes in the groin and pelvis to determine if they are affected by cancer.

'''Laboratory tests:'''

'''Blood and urine:''' Tests may include a complete blood count, liver and kidney function tests, and other specific markers that can help assess overall health.

'''Cytology and histopathology:'''

'''Histopathological analysis:''' The biopsy sample is analyzed under a microscope to confirm the presence of cancer and determine the type and stage of the disease.

'''Urogenital ultrasound:'''

'''Ultrasound:''' rarely used for vulvar cancer, it can help assess the involvement of surrounding structures and in monitoring the disease.

<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 the stage of endometrial, cervical, vaginal or vulvar cancer and the patient’s general health.

'''Treatment options'''

'''Endometrial cancer'''

'''Surgery:'''

'''Hysterectomy:''' Removal of the uterus and usually the fallopian tubes and ovaries. It is the most common treatment for endometrial cancer.

'''Radical hysterectomy:''' Removal of the uterus, cervix, vagina, and surrounding lymph nodes, often used in advanced cases.

'''Radiotherapy:'''

'''External beam radiotherapy:''' Uses an external source of radiation to target the tumor.

'''Internal (brachytherapy) radiotherapy:''' Radiation is delivered directly inside the uterus or vagina.

'''Chemotherapy:''' Used in advanced stages of cancer or if there is a risk of recurrence. Chemotherapy may include drugs such as doxorubicin, paclitaxel, or carboplatin.

'''Hormone therapy:''' Used if endometrial cancer expresses hormone receptors (estrogen or progesterone). Medications such as progestins can help control tumor growth.

'''Targeted therapy and immunotherapy:''' These therapies are being investigated and used in specific cases. They target specific molecules or cancer cells, and immunotherapy activates the immune system to attack cancer cells.

'''Cervical cancer'''

'''Surgery:'''

'''Conization:''' Removal of a small cone-shaped portion of the cervix for diagnosis and treatment in the early stages.

'''Hysterectomy:''' Removal of the uterus and cervix. May include removal of the ovaries and fallopian tubes.

'''Radical hysterectomy:''' Removal of the uterus, cervix, upper part of the vagina, and surrounding lymph nodes. Used for advanced stages.

'''Radiotherapy:'''

'''External beam radiotherapy:''' Helps destroy cancer cells outside the body.

'''Internal (brachytherapy) radiotherapy:''' Delivers radiation directly inside the cervix or vagina.

'''Chemotherapy:''' Often used in combination with radiation therapy for advanced stages of cervical cancer. Medications include cisplatin, paclitaxel and topotecan.

'''Immunotherapy:''' Under investigation for advanced or recurrent cases of cervical cancer. The goal is to stimulate the immune system to fight cancer.

'''Vaginal cancer'''

'''Surgery:'''

'''Excisional biopsy:''' Removal of the tumor and a portion of surrounding healthy tissue. May include removal part of the vagina.

'''Hysterectomy:''' Removal of the uterus, cervix, and part of the vagina if necessary.

'''Radiotherapy:'''

'''External beam radiotherapy:''' Used to treat tumors outside the vagina.

'''Internal (brachytherapy) radiotherapy:''' Application of radiation inside the vagina to directly target tumor.

'''Chemotherapy:''' Used in combination with radiation therapy for advanced cases. Medications include cisplatin, paclitaxel, and 5-fluorouracil.

'''Immunotherapy and targeted therapies:''' Under investigation for specific cases. They target specific molecules and help the body fight cancer.

'''Vulvar cancer'''

'''Surgery:'''

'''Excision:''' Removal of the tumor and surrounding healthy tissue. This may include local excision only or a wider resection, depending on the size and stage of the tumor.

'''Radical vulvectomy:''' Removal of the entire vulva, sometimes including nearby lymph nodes.

'''Radiotherapy:'''

'''External beam radiotherapy:''' Used to treat tumors outside the body.

'''Internal (brachytherapy) radiotherapy:''' Helps treat tumors inside or near the vulva.

'''Chemotherapy:''' Less commonly used for vulvar cancer, but may be indicated in advanced stages or if the cancer spread to other parts of the body. Chemotherapy may include drugs such as cisplatin or 5-fluorouracil.

'''Immunotherapy and targeted therapies:''' Under investigation and application for specific types of vulvar cancer, by targeting specific molecules or activating the immune system to fight cancer.

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

'''Endometrial cancer'''

'''Follow-up:'''

'''Regular checkups:''' After treatment, patients usually undergo regular gynecological examinations and transvaginal ultrasound to monitor for possible recurrence illness.

'''Marker monitoring:''' Blood tests may be done periodically to monitor levels of tumor markers if they were elevated before treatment.

'''Radiological examinations:''' CT scans or MRIs may be used to assess the eventual spread of disease or recurrence, especially if there is suspicion of recurrence illness.

'''Rehabilitation:'''

'''Physical rehabilitation:''' May include exercises to improve strength and flexibility after surgery and radiation therapy.

'''Psychological support:''' Counseling or therapy to help cope with stress and anxiety after diagnosis and treatment.

'''Survival:'''

'''Prognosis:''' Five-year survival for endometrial cancer depends on the stage of the disease, the type of cancer, and response to treatment. In the early stages, survival can be very high (over 80%), while in advanced cases it can be lower.

'''Monitoring:''' Long-term monitoring is important for early detection of possible recurrence of the disease or development of secondary carcinomas.

'''Cervical cancer'''

'''Follow-up:'''

'''Regular checkups:''' After treatment, patients undergo regular gynecological examinations, including the PAPA test and the HPV test, to monitor the condition of the cervix and early detect recurrence of the disease.

'''Imaging tests:''' If recurrence is suspected, CT scans, MRIs, or PET scans may be used.

'''Rehabilitation:'''

'''Physical rehabilitation:''' Exercises to improve overall health and functionality after surgery and radiotherapy.

'''Rehabilitation of sexual health:''' Counseling on sexual health and coping with changes that may affect sex life.

'''Psychological support:''' Support for mental health, including therapy or counseling to help cope with the emotional consequences of illness.

'''Survival:'''

'''Prognosis:''' Five-year survival for cervical cancer depends on the stage of the disease, with survival around 90% in the early stages and significantly lower in the advanced stages.

'''Monitoring:''' Long-term monitoring for early detection of recurrence and assessment of general health.

'''Vaginal cancer'''

'''Follow-up:'''

'''Regular checkups:''' After treatment, regular follow-up with a gynecologist is necessary to detect possible recurrence or metastases.

'''Imaging tests:''' If recurrence is suspected, CT scans or MRIs may be used for evaluation.

'''Rehabilitation:'''

'''Physical rehabilitation:''' Exercises to improve strength and flexibility.

'''Rehabilitation of sexual health:''' Counseling on sexual health and techniques for coping with changes that may affect sex life.

'''Psychological support:''' Support for mental health, including therapy or counseling to help cope with the emotional consequences of illness.

'''Survival:'''

'''Prognosis:''' Five-year survival for vaginal cancer depends on the stage and type of cancer. In early stages, it can be around 50-60%, while in advanced stages, it can be lower.

'''Monitoring:''' Long-term monitoring for early detection of recurrence or metastases.

'''Vulvar cancer'''

'''Follow-up:'''

'''Regular checkups:''' After treatment, patients usually have regular gynecological examinations to monitor vulvar health and detect any possible recurrence of cancer.

'''Imaging tests:''' If recurrence is suspected, CT scans or MRIs may be used.

'''Rehabilitation:'''

'''Physical rehabilitation:''' Exercises to improve circulation, reduce swelling and restore functionality after surgery.

'''Pelvic floor rehabilitation:''' Special exercises to strengthen the pelvic floor muscles can be helpful, especially after radical vulvectomy.

'''Psychological support:''' Counseling or therapy to help cope with the emotional and psychological consequences of vulvar cancer.

'''Survival:'''

'''Prognosis:''' Five-year survival depends on the stage of the disease and the effectiveness of treatment. In the early stages, survival may be higher than 70%, while in advanced stages, it may be significantly lower.

'''Monitoring:''' Long-term monitoring for early detection of recurrence or metastases.

<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:''' Medicines, nerve blocks.

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

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

'''Treatment of difficult urination:''' If problems with urination occur, catheters or medications may be used used to relieve symptoms.

'''Management of itching and irritation in vulvar cancer:''' Use of creams and ointments to reduce itching and irritation.

<span id="challenges-faced-by-patients-with-endometrial-cervical-vaginal-and-vulvar-cancer-during-their-therapeutic-journey"></span>
= Challenges faced by patients with endometrial, cervical, vaginal and vulvar cancer during their therapeutic journey =

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

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

'''Physical challenges'''

'''Symptoms of the disease:''' bleeding and pain in the lower abdomen, which can cause discomfort and anxiety, problems with urination.

'''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 due to illness and the need for privacy.

'''Financial and professional challenges'''

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

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

'''Physical challenges'''

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

'''Problems with nutrition:''' Difficulty eating due to nausea, loss of appetite, or problems with swallowing.

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

'''Hair loss (alopecia):''' Chemotherapy can cause temporary hair loss.

'''Anemia:''' Decreased number of red blood cells, which can cause fatigue and weakness.

'''Infections:''' Decreased white blood cells increase the risk of infections.

'''Scars:''' Aesthetic and functional consequences of surgical incisions.

'''Skin reactions:''' Rash, itching and dry skin.

'''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 for daily 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 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 infections during therapy.

'''Financial and professional challenges'''

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

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

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

'''Lack of information'''

The need to understand complex medical information and make informed decisions. Difficulties in making decisions about treatment due to the lack of reliable and understandable information or conflicting advice.

Ignorance of patient rights.

Lack of information on healthcare providers during treatment.

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

'''Physical challenges'''

'''Chronic fatigue:''' Feeling exhausted that lasts for weeks or months after treatment ends.

'''Muscle weakness:''' Decreased 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 a consequence of stress, pain or a side effect 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 therapy.

'''Psychological challenges'''

'''Fear of recurrence:''' persistent fear of cancer recurrence. Anxiety and depression: psychological stress and emotional problems associated with the experience of cancer.

'''Social Isolation:''' Decreased Social interaction due to fatigue, anxiety, or other symptoms.

'''Financial and professional difficulties'''

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

Long-term financial burden associated with ongoing medical expenses.

'''Coordination of health care'''

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

Patients with vaginal, vulvar, endometrial or cervical cancer face various challenges during their diagnostic, therapeutic and rehabilitation journey, including physical, psychological, financial and professional difficulties, lack of information, and coordination health care. Providing comprehensive support that includes medical care, psychological support, education and social services can significantly improve quality of life and treatment outcomes for these patients.

<span id="supportive-activities-for-patients-with-endometrial-cervical-vaginal-and-vulvar-cancer"></span>
= Supportive activities for patients with endometrial, cervical, vaginal and vulvar 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 patients with one of these cancers, helping them to more easily cope with the problems that the disease and treatment brings.

Civil society organizations, such as patient associations and cancer advocacy organizations, can play a key role in informing patients about such support activities. Also, associations can organize and provide some of the necessary support to patients themselves with the help of experts in order to reducing 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="support-activities-provided-by-institutions-health-care"></span>
== Support activities provided by institutions health care ==

'''Supportive activities for physical challenges'''

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

'''Family medicine doctor:''' takes care of everyday health needs during and after treatment

'''Oncologist:''' overall treatment management

'''Nutritionist:''' counseling on diet and weight management.

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

'''Psychologist:''' helps with emotional issues.

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

'''Supportive activities for psychological difficulties'''

Patients with cancer and their families almost invariably face numerous challenges psychological difficulties throughout the entire therapeutic journey. Professional psychological help in the form of individual counseling, group therapy work, counseling with a partner and family counseling is a key part of support for cancer 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 treatment led to mutual understanding. Detailed but easy-to-understand educational content for patients is essential in that process, but they are often not available.

The right to a second medical opinion: guaranteed by the Patient Rights Act. The patient has always entitled to seek a second medical opinion on their health. Every healthcare professional must provide a second medical opinion to the patient upon an oral or written request high professional qualifications and appropriate specialization, who did not participate in the direct provision of a certain type of health service to the patient. In addition to the patient, the doctor is the one who can initiate the process of seeking a second opinion. In the case of diagnosis of a rare disease, the inability to find (adequate) therapy, inadequate technological equipment health care institution that prevents or makes it difficult to establish a diagnosis or course of therapy, doctors often seek help and confirmation from their colleagues from other institutions in order to provide the best 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 informational activities that educate patients on ways to manage side effects. Providing brochures and online resources with practical advice.

'''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, eating 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 collaboration of fitness and nutrition experts for personalized recommendations for moderate exercise. Organizing practical workshops for proper nutrition, creating educational materials.

'''Support activities for psychological challenges'''

Providing 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 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 changes.

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 experts in sexual health.

Organizing family therapy sessions and workshops that involve 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.

'''Support activities for financial and professional challenges'''

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

Organizing workshops on workers’ rights.

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

Providing information on 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 the disease and treatment:''' education and information materials. Organizing educational seminars and workshops with medical professionals. Distribution of brochures and online resources on the disease and treatment.

'''Supportive activities on patient rights'''

Information on rights and social assistance options is provided. You can find everything about patient rights at this link 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 patients with endometrial, vulvar, vaginal or cervical cancer. These groups often offer a system of peer support 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 in order to inform and educate patients to empower them to actively participate in the treatment process.

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

A large number of civil society organizations operate in Croatia, providing support to cancer patients. There are a larger number of associations in Croatia in the directory, while here we single out a few:

'''Oncology Association'''

Address: Šenoina 7, 10 000 Zagreb

Phone: +385 1 4624558

Website: udruga-onkologija.hr

'''Association “EVERYTHING for HER”'''

Address: Dr. Franje Tuđmana 4, 10 000 Zagreb

Phone: +385 1 4824 275

Website: svezanju.hr

'''Croatian Health Assembly'''

Address: Zvonimirova 32, 10 000 Zagreb

Phone: +385 1 3881484

Website: hzz.hr

'''Association “Woman Founder”'''

Address: Ul. kneza Mislava 9, 10 000 Zagreb

Phone: +385 1 4826666

Website: zena-udruga.hr

'''Association “Angels”'''

Address: Branimirova 31, 10 000 Zagreb

Phone: +385 1 4880715

Website: udruga-anjeli.hr

'''Association “We are not alone”'''

Address: Ulica grada Vukovara 284, 10 000 Zagreb

Phone: +385 1 6332 737

Website: nismosame.hr

Website: iget.hr

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

The Croatian translation of several Patient Guides was made by the Association of Women with Cancer and those treated for cancer EVERYTHING for HER on the basis of the approval of the European Society for Medical Oncology (ESMO).

'''ESMO Patient Guide Living with Cancer''' This Patient Guide to Living with Cancer 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 people like you during this important time in your life.

In this Guide, you can find information on support in coping with the new life situation, life after primary treatment, preventive care and long-term follow-up. It will also help you keep a personal health record, or plan your health care during life with cancer.

The guide was translated by Dea Ajduković, PhD, and the translation was reviewed by Natalija Dedić Plavetić, PhD, prim. dr. med. specialist. int. oncology and on behalf of patients psychologist Ljiljana Vukota from the EVERYTHING for HER association.

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

'''ESMO Personalized medicine in oncology: A guide for patients'''

This Patient Guide was initiated by the ESMO Personalized Medicine Working Group to help patients, their families and friends to better understand the factors that can 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 to several types of tumors. Personalized medicine represents the future of cancer treatment, and in order for it to become a reality in the near future and enable better therapy tumors, the role of patients is crucial.

The Croatian translation of the Guide was made possible by the Association of Women with Cancer and those treated for cancer EVERYTHING for HER on the basis of the approval of the European Society for Medical Oncology (ESMO). Text The Croatian translation was reviewed by: Prof. Ljiljana Šerman, prof. Floriana Bulić-Jakuš i Mrs. 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: Patient Guide'''

This guide has been prepared to help you and your family, friends and caregivers to better understand the side effects associated with immunotherapy and their management. It contains information about the most common toxicities associated with modern immunotherapies (known as “immune checkpoint inhibitors”), how to Your oncology team can address these symptoms and a few approaches you can take yourself to reduce their effects. Medical information described in this document is based on ESMO Clinical Practice Guidelines for the Management of Immunotherapy Toxicity, which are designed to help clinicians in diagnosing, treating and monitoring these events. All ESMO guidelines for clinical practice are prepared and reviewed by leading experts using evidence obtained the latest clinical trials, scientific research and expert opinions.

The Croatian translation of the guide was reviewed by: 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 recovered from cancer EVERYTHING for HER: Ljiljana Vukota.

'''ESMO Cancer treatment during the Covid-19 pandemic: A guide for patients'''

The guide contains information about COVID-19 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 may be necessary to protect yourself from infection.

The Croatian translation was reviewed by: Prim. Dr. Sc. Paula Podolski, president of the Croatian Society of Senology, Doc. Dr. Sc. Borislav Belev, medical oncologist, National representative of the Croatian Society for Internal Oncology at ESMO and Ljiljana Vukota, representative of EVERYTHING 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 finding in cancer patients and is a consequence of the presence of a tumor and medical and surgical treatments for cancer.

Malnutrition negatively affects the quality of life and the toxicity of treatment, 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 diagnosis of cancer, within the diagnostic and therapeutic pathway, and should be carried out in parallel with antineoplastic treatment. However, worldwide, cancer-related malnutrition is still largely unrecognized, underestimated, and undertreated in clinical practice.

These evidence-based guidelines have been developed to translate the best available evidence and expert opinion into recommendations for multidisciplinary teams responsible for identification, prevention and treatment of reversible elements of malnutrition in adult cancer patients.

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

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

'''Croatian League Against Cancer'''

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

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, development of information 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 engaged in 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 health services.

Counselling: 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 Prostate Cancer Patient Association (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 about prostate cancer prevention and early detection, organization 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 Thyroid Patients'''

Activities: Providing individual and group psychological support to patients with thyroid disease, organizing workshops, lectures, and distributing educational materials about thyroid diseases, counseling and support for patients in the rehabilitation process after treatment, campaigns to raise awareness about thyroid diseases and the importance of early detection and treatment, Information platform that provides advice on diet, 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 assistance, financial assistance, 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 assistance.

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 ==

'''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 of the Šibenik-Knin County'''

Offer: Education, support groups, psychological help.

Contact:

Address: Trg Nikole Tomasea 2, 22000 Šibenik

Phone: 022 218993

Email: liga.sibenik@gmail.com

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

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

'''Mammae Club Varaždin Association'''

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 League Against Cancer Vinkovci

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

'''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/