Project considered by the Preparation and Assessment Committee (PAC) on 16/11/04 and approved by the Approval Board (AB) on 17/11/04 as the CORE Programme Topical Project

Background:

A dramatic increase of incidence of thyroid cancer in people affected by radiation in child age in Gomel and Brest regions is considered to be the most serious and recognized medical consequence of Chernobyl nuclear plant disaster.

Medical help to patients with radiation induced thyroid cancer in Belarus (over 2000 patients are children and young adults), is characterized by a high level of early diagnosing of this disease - 22%, and adequate surgical treatment. At the same time, there are certain difficulties with Radioiodine therapy availability according to the berth fund insufficiency and dependence on foreign radioiodine supplies. An adequate holding of suppressive therapy with levothyroxine under constant thyrotropin hormone and thyroglobulin levels control for early revealing of the disease progression is another specific problem. In our Republic, holding of the suppressive therapy without proper control has caused a number of side effects, worsening patient's condition (decreased height/weight indexes in children in 50%, cardio-vascular system damage - 30%, respiratory impairments - 20%, phosphorus-calcium metabolism -10%). Furthermore, holding of series of Radioiodine therapy courses causes changes in reproductive system (aspermia in men, hormonal dysfunctions in women).

In recent years, the fastest growth rates of incidence of radiation induced thyroid cancer in Belarus are observed in Stolin, Luninets and Pinsk regions.

By statistical data, there are 153 patients with the radiation induced thyroid cancer being on dispensary follow up by the January 1, 2004, in Stolin region. And the majority of them (86 persons - 52%) consists of young people of reproductive age, who were affected by the radiation at child or adolescent age during the Chernobyl disaster. It must be stressed, that in Stolin region with the population about 86,7 thousand people, unlike the most contaminated districts of Gomel region (Bragin, Hojniki, Narovlya, Chechersk) no settling out on medical indications is being held, and major part of the patients continues living on contaminated areas.

Thus, a large amount of new cases of thyroid cancer (11,5 per 100 000 people) is observed in Stolin region, along with the incidence of 176,5 cases per 100 000 people, herewith 5,4 cases per 100 000 of children and 157,1 cases per 100 000 of adolescents. There are 53 adolescents and 1 637 adults with nodular nontoxic goiter being dynamically followed up by endocrinologist of Stolin Regional Territorial Medical Department. 1 adolescent and 60 adults with thyrotoxicosis, 36 adolescents and 697 adults with thyroiditis are also on dynamic follow up. There were 593 cases of various thyroid pathology registered among adolescents. 60 cases were diagnosed for the first time. 3 596 cases of thyroid pathology were registered among adults, 243 cases - for the first time. During first 9 months of the year 2004, 379 cases of thyroid pathology were registered among children, 57 of them - for the first time. 328 out of 379 cases - nontoxic diffuse goiter, 14 cases with nodular forms, 26 cases - with thyrotoxicosis, 6 cases of hypothyroidism (2 acquired, 4 - congenital). In total there are about 5000 of patients with various thyroid pathology, being dynamically followed up.

The peculiarity of the situation in Stolin region is in the presence of large amount of families, having many children, according to the traditions of religious denomination. Repeated pregnancies and deliveries in patients with thyroid cancer cause decompensation of their condition and require doctors to pay more attention to the condition of the babies and further rehabilitation of their mothers.

Wile questioning patients with thyroid pathology, main problems were revealed: due to financial limitations patients are not always able to buy Levothyroxine, Calcium, vitamin D. Unavailability of regular thyroid hormonal status control in local hospitals at the place of residence of the patients. Consultations with specialists in central Republican institutions are also unavailable because of high transportation costs. Patient oriented medical information is also absent in sufficient amounts. Holding of preliminary medical investigations showed, that almost 80% of thyroid cancer patients in Stolin region, do not have a complete protocol examination because of the absence of necessary laboratory and diagnostic equipment in the region.

All foregoing indicates the necessity of working out of the effective measures in addition to the existing in the frames of state healthcare system of rehabilitation of patients. During last 5 years the following methodical recommendations were worked out by professor V.M.Drozd in partnership with prof. Christof Reiners (Clinic of Nuclear Medicine of Wuerzburg University, Germany) for the creation of conditions for more full-fledged (full-valued) rehabilitation of patients with thyroid cancer: "Medical rehabilitation of children with thyroid carcinoma", 1999; information for the patients "What should the patients know, after the operation on thyroid gland", 2003; "Endocrinological aspects of rehabilitation of patients being under thyroid cancer complex therapy", 2004. However, the accumulated experience requires further efforts on it's introduction in to a practical healthcare.

Taking into consideration social aspects of disablement (physical impairment) of patients with radiation induced thyroid cancer it is actual to organize the project on improvement of rehabilitation and medical aid on the place of residence of these patients.

A number of tendencies, observed currently due to official statistical data, concerning Stolin region, points to the necessity of creation of the project, aimed to improve the rehabilitation of the patients with thyroid cancer and other thyroid pathology. A continuous growth of incidence of nodular pathology and thyroid cancer among adolescents and young adults is marked. Holding of the suppressive therapy with levothyroxine without proper control, because of the absence of necessary equipment on regional level has caused a number of side effects, worsening thyroid cancer patient's condition.

Often patients with thyroid cancer apply for medical aid to different specialists, like therapeutist, gynecologist, andrologist, bat doctors of local healthcare are not always aware of contemporary protocols of treatment of this disease, and sometimes give contradictory recommendations. So there were some cases of ungrounded interruption or prohibition for pregnancy preservation met.

Geographical remoteness of Stolin region from the Republican Endocrinologycal center in Minsk and from Gomel SPC RM and HE, and also high transportation costs reduces availability of the specialist's consultations.

The task of the protocol is holding of the full-valued rehabilitation of patients with thyroid cancer, optimization of the social status, reassessment of patient's consciousness from a "victim of the disease" in to a fully valuable personality.

The main strategic components of the suggested project are:

1. Making the qualified specialized medical aid more available at the place of patients' residence .
2. Shaping of patients' active co-participation by increasing their awareness of the course of their disease .

Aim and Objectives of the Topical Project (TP):

The main aim of the project is an improvement of rehabilitation of the patients with radiation induced thyroid cancer and other thyroid pathology in Stolin region, by making the qualified specialized medical aid more available at the place of patient's residence and increasing of their awareness about the disease, life quality and social activity.

Main objectives:

1. Work out a program of staged rehabilitation of patients with thyroid cancer and other thyroid pathology in Stolin region for exact conditions of local healthcare and Republican level healthcare (Republican centre of Medical Rehabilitation and Water therapy, Belarusian Medical Academy of Postgraduate Education). The program is also grounded on shaping patients' co-participation by increasing their awareness of the course of their disease.
2. Investigate the demand and organize the supply of necessary medications (Levothyroxin, Calcium, Vitamin D and antioxidant complexes) for improved rehabilitation of patients..
3. Organize purchase of equipment for thyroid status monitoring to provide a possibility for local hospitals to perform main analyses determining thyroid function.
4. Perform screening examinations of Stolin region population to reveal factors distinctive for Stolin region, affecting the development of thyroid pathology and worsening patients' condition (iodine and other microelement insufficiency, presence of pollutants such as nitrites, nitrates, and cesium).
5. Provide necessary conditions (computer purchase, Internet availability) for involvement of the Stolin Regional Territorial Medical Department in teleconsultations network in order to increase the quality of medical aid.
6. Provide methodological assistance for improvement of qualification of doctors and nurses in the following areas: therapy and follow up of patients with thyroid cancer and other thyroid pathology, laboratory diagnostics, radiation safety and medical consequences of radiation influence.
7. Prepare easily comprehensible brochures for the patients about thyroid diseases and organization of patients' education in the regional hospital or out-patient department.

Local, national and international partners of the Topical Project:

Local partners :

Stolin Regional Hospital, Village Outpatient Department, Almany village.

• Form a cohort of patients for consultative medical help; take part in improvement of schemes of staged rehabilitation of patients with thyroid pathology and approbation of these schemes on local level.
• Takes part in forming of partner's relations with the patients and members of their family.
• Performs a choice of specialists (pediatricians, endocrinologists, gynecologists, oncologists, medical assistants of local outpatient departments) for their participation in trainings and seminars.
• Performs examination and dynamic follow up of the patients.

Stolin Regional Territorial Medical Department
Phone: +375 1655 229 84
Fax: +375 1655 246 67
E-mail: stolin-hospital@brest.by
Contact person: Misiura Raisa Alexeevna - assistant director of the Clinic of childhood and delivery-helping of Stolin RTMD

National partners :

1. International Belarusian-German Fund "Aid for Radiation Induced Thyroid Cancer Patients "ARNICA"

• Performs a personnel selection for the participation in the program (doctors, teachers, social workers).
• Performs medical examination of patients and their dynamic follow up.
• Takes part in patient's examination and laboratory tests quality control.
• Takes part in analysis of the data received, introduction of the results, in preparation of the reports and publications.

Postal address:

International German-Byelorussian Fund "Aid for Radiation Induced Thyroid Cancer Patients "ARNICA",

7 Yanka Kupala Str., Minsk, Belarus, 220030
Phone: +375 172 27 11 74
Fax: +375 172 01 37 31
E-mail: drozd@users.med.by
Contact person: Professor Drozd Valentina Mihajlovna, director.

2. Belarusian Medical Academy of Postgraduate Education, Endocrinology Department.

• Conducts lectures and seminars aimed at raising the level of doctors' professional skills.
• Participates in preparation of methodical literature.

Postal address:

3 Pyatrus Brovka Str., Minsk, Belarus
tel.: + 375 172 40 57 22 , e-mail : lglada@belsonet.net
Contact person: head of the department, Prof. Danilova L.I.

3. The Joint Institute of the Problems of Informatics of the National Academy of Science of Belarus

• Implements preparatory work of defining the configuration of telemedical communications;
• Develops the software;
• Offers the Internet providing services.

Postal address :

6 Surganov Str., Minsk, Belarus, 220012
tel.: + 375 172 84 21 40, fax: + 375 172 3184 03 , e-mail: tuzikov@newman.bas-net.by
Contact person: Tuzikov A.V., Dr of Physico-mathematical Sciences, General Director Assistant

International partners :

S ocial association "Medical Help for Chernobyl Children" on the base of Clinic and Polyclinic of Nuclear Medicine, Wuerzburg University, Wuerzburg, Germany

• Do the selection of methodical literature.
• Implement holding of trainings, seminars for the personnel of the project.
• Take part in project quality control.
• Take part in discussion of the results received and preparation of the publications.

Postal address: Social association "Medical Help for Chernobyl Children" on the base of Clinic and Polyclinic of Nuclear Medicine, Wuerzburg University,
2 Josef Schneider Str., Wuerzburg, D-97080, Germany
Phone: +1049 931 201 5875
Fax: +1049 931 201 5876
E-mail: reiners@nuklearmedizin.uni-wuerzburg.de

Detailed description of the TP stages

Direction 1. Working out of the program of staged rehabilitation of patients with thyroid cancer and other thyroid pathology in Stolin region.

• Study current medical conditions of the rehabilitation of patients with thyroid cancer and other thyroid pathology in Stolin region.
• Work out an algorithm of staged rehabilitation of thyroid cancer patients in accordance with the abilities of healthcare on local (Stolin RTMD) and Republican ( Republican centre of Medical Rehabilitation and Water therapy, BelMAPE, SPC Radiation medicine and Human Ecology) levels.
• Work out a complex of rehabilitation procedures, aimed to preserve fertility in thyroid cancer patients, undergoing radioiodine therapy.
• Forming of co participation between doctors, patients and patients' family members - as a guarantee for successful rehabilitation.

Direction 2. Improvement of the logistics of the regional hospitals and supply of the needed medications to the patients.

• Supply of the necessary equipment (IFA-analyzers, diagnostic reagents) to the Stolin RTMD. Organize the availability of thyroid hormonal status control at the regional level.
• Supply of sufficient amount of medications of levothyroxine, calcium, vitamin D, and antioxidant complexes.

Direction 3. Medical screening of the population to reveal the real incidence of thyroid pathology.

• Ultrasound screening of Stolin region risk-group-population: people affected by radiation at the age of less than 5 years old, pregnant women and children living on radionuclide contaminated areas.
• Systematic follow up of thyroid cancer patients in accordance with standard protocol, early revealing of cancer relapse and other complications.
• Reveal the reasons of high incidence of thyroid pathology and risk-factors for its development in Stolin region.

Direction 4. Involvement of Stolin region in to the teleconsultations network.

• Equipping of Stolin RTMD with computers and introduction of telemedicine consultations.
• Provision of Internet availability
• Installation of special software, automated working places for the doctors of different specialties in Stolin regional hospital.
• Performance of Teleconsultations on regular basis.

Direction 5. Improvement of professional level of Stolin region medical workers and increase of awareness of the patients about their disease.

• Holding of educational seminars on different aspects of endocrinology among medical workers of local healthcare units.
• Holding of educational work among patients with thyroid pathology, supply of patient-oriented medical literature.
• Publishing of special and popular medical literature.
• Organization of Thyroid Patient School in Stolin region.
• Forming of co-participation with the patients by informing them about the course of their disease, by acquainting them with the popular medical literature.

Expected results of the TP

Expected results of the TP are early revealing of thyroid cancer at the stage 1, early revealing of the relapses and progression of the disease, early diagnosing of the other thyroid pathology. Improvement of the rehabilitation of the patients (normalization of the thyroid hormonal status control, decrease of social tension, because of the absence of the high-quality medical aid and necessary medications. Improvement of supply of the equipment to Stolin region. Provision of the popular medical literature to the patients. Improvement of the doctors' qualification. Availability of the qualified medical aid by means of the Telemedicine Consultations. Improvement of general health condition and social adaptability of the patients with radiation induced thyroid cancer.

Criteria of Efficiency of the TP:

• Amount of patients, revealed at the early stage of the disease or with the progression of thyroid pathology.
• Optimization of dynamic follow up, rehabilitation, social adaptation of young patients with radiation induced thyroid cancer.
• Increase of the number of patients with the adequate thyroid hormonal status.
• Preservation of fertility and provision of the possibility to give birth to a healthy child in patients with thyroid cancer.
• Improvement of equipment of Stolin RTMD with laboratory and computer techniques.

Availability of Internet and performance of regular teleconsultations

Coordination and integration of TP in the program CORE

The announced thematic project completely corresponds common direction of the program CORE to the prevention of health and improvement of the rehabilitation of the patients, whose diseases are a consequence of Chernobyl disaster and who live on contaminated territories.

• Once a year an informing of local, national and international partners about the development of the TP will be performed in the framework of the Committee on Healthcare Priority Relations.
• The estimation of the results of the TP will be performed during yearly presentations for the Program Core Coordination Structures, and in the framework of the seminars in Stolin region.

TP will be performed in collaboration with the participants of the project "Healthy Mothering", performed by the Brest branch of the Institute of Radiology and organization "Doctors for Peace" (Doctors of Peace) in Stolin region.

Budget, €

Schedule

All Rights Reserved, CORE, 2004