Lessons from Ireland: weaving the care continuum in the systemic treatment of cancer

The cancer treatment phase has changed profoundly. For years, much of the healthcare system has been built around a recognizable image: the patient who comes to the day hospital to receive chemotherapy. That image still exists, but it is no longer sufficient to explain the current reality.

For the purposes of this discussion, the focus is on systemic antineoplastic treatments , understood as the set of therapies aimed at treating or controlling cancer through systemic action. This includes chemotherapy, immunotherapy, targeted therapies, hormone therapy, oral antineoplastic treatments, combination therapies, maintenance therapies, and associated supportive care.

Other local or locoregional therapeutic modalities, such as surgery or radiotherapy, fall outside the specific scope of this discussion. This is not because they are unrelated to the oncological process, but because they follow different care approaches. However, their coordination with systemic treatment is essential within the oncological care continuum.

Clinical practice has diversified, medical decisions have become more complex, and the systemic therapeutic phase has become one of the most demanding parts of the oncological process. In this context, international experiences based on SACT—Systemic Anti-Cancer Therapy— show that the systemic cancer treatment phase should be understood as a critical segment of the care continuum, especially in a scenario of increasing therapeutic diversification and clinical complexity.

Ireland offers a particularly interesting example. Through its National Cancer Control Programme (NCCP) , the Irish healthcare system has developed a specific approach to systemic cancer treatment, not only as a pharmacological category but as a true model of care . Its approach incorporates service organization, governance, quality, safety, patient experience, and the definition of care pathways.

From chemotherapy to systemic treatment

The first lesson from Ireland is conceptual. The SACT concept allows us to move beyond a view limited to chemotherapy and to organize, under a single framework, all the pharmacological treatments used to control or treat cancer: chemotherapy, immunotherapy, targeted therapies, hormone therapy, oral antineoplastic treatments, and therapeutic combinations.

This change is not merely terminological. Properly naming the process allows for better management. If we continue to speak only of "chemotherapy," we risk limiting our focus to a single type of treatment and a specific moment of administration. However, if we speak of systemic antineoplastic treatment , we can incorporate the true complexity of the process: indication, validation, preparation, administration, monitoring, toxicity, continuity, and reassessment.

It also allows for a better understanding of the complexity of medical decision-making. The choice of treatment no longer depends solely on the overall diagnosis, but on multiple variables: stage, biomarkers, functional status, comorbidities, previous treatments, toxicity profile, patient preferences, therapeutic objectives, and availability of alternatives.

The medical decision ceases to be an isolated point and becomes part of a sequence that is adjusted throughout the process.

Treatment as a critical segment of the care continuum

The second lesson is organizational. Systemic cancer treatment cannot be understood as an isolated episode. Each therapeutic decision depends on prior information—diagnosis, stage, biomarkers, clinical status, previous treatments—and influences subsequent decisions: dose adjustments, delays, discontinuations, changes in treatment regimen, response assessment, or management of toxicities.

From this perspective, systemic treatment acts as a hinge within the cancer care continuum. It connects diagnosis with therapeutic strategy, pharmacy with clinical practice, administration with follow-up, and tumor response with the next care decision.

The underlying idea is clear: the more complex the treatment becomes, the more necessary it is to link the process together.

And this need doesn't just affect the organization. It also affects clinical decision-making. The professional must decide not only what treatment to prescribe, but when to start it, when to delay it, when to modify the dose, when to discontinue it, when to change the treatment approach, when to intensify monitoring, and when to activate other care mechanisms.

Therapeutic proliferation as an organizational challenge

The diversification of cancer treatments not only expands clinical options, but also increases the organizational complexity of the system.

Each new treatment may incorporate new indication criteria, new biomarker requirements, new preparation conditions, new toxicities, new authorization pathways, new patient information needs, and new forms of follow-up.

Therefore, therapeutic innovation not only impacts individual clinical decisions, but also the architecture of the care process.

Ireland has developed national SACT regimens for various tumor groups, including oral antineoplastic drugs and supportive care. This approach aims to support safer prescribing, dispensing, and monitoring based on common protocols.

The lesson is relevant: therapeutic complexity requires intelligent standardization . Not to replace medical decision-making, but to support it. Not to make clinical practice more rigid, but to ensure that each treatment is part of a safe, traceable, and coordinated system.

Beyond the day hospital

Another interesting contribution of the Irish model is that it does not limit systemic treatment to the day hospital. It also includes local and community services for certain treatments and supportive care, always under criteria of safety, patient selection, governance, and clinical review.

This does not mean indiscriminately moving treatment out of the hospital. It means differentiating what can be done where, in which patients, with which treatments, under what conditions, and with what follow-up mechanisms.

In terms of process, this is a central issue. The continuum of care is not woven solely within the walls of the hospital. It is also woven when the system decides what part of the follow-up can be brought closer to the patient, which toxicities should trigger alarm circuits, what information should be available to different professionals, and how continuity is maintained between the hospital, the community, and the patient.

Here too, the medical decision becomes more complex. It is not enough to decide on the treatment; one must also decide on the appropriate environment in which to administer or monitor it.

Breast cancer as a particularly relevant example

Although the reflection is not limited to a specific pathology, breast cancer allows us to observe with particular clarity the importance of this approach.

The care process for breast cancer combines screening or clinical suspicion, diagnostic imaging, biopsy, pathology, molecular characterization, tumor board, surgery, radiotherapy, systemic treatment, follow-up, and, in many cases, prolonged survival or advanced disease. Precisely for this reason, systemic treatment cannot be understood as an isolated phase, but rather as a segment connected to multiple prior and subsequent decisions.

In breast cancer, therapeutic diversification is particularly evident. The indication may depend on the tumor subtype, hormone expression, HER2 status, other biomarkers, stage, the patient's functional status, the neoadjuvant, adjuvant, or metastatic context, previous treatments, and the clinical objectives at any given time.

This transforms decision-making into a longitudinal process. It's not just about choosing a treatment, but about structuring timelines, combining modalities, assessing response, managing toxicities, deciding on maintenance therapy, anticipating relapses, and coordinating follow-up.

Therefore, breast cancer serves as a good tracer case to understand the underlying thesis: the more diversified the therapeutic alternatives become, the more necessary it is to organize systemic treatment as part of the care continuum.

It is not enough to simply have more options. It is necessary to ensure that each option is part of a process capable of supporting complex clinical decisions, professional coordination, shared information, safety, and continuity.

What Ireland teaches about process analysis

From the perspective of the Venturi Project, the Irish experience allows us to draw a particularly useful lesson: the systemic cancer treatment phase should be analyzed as a macro-process , not as a sum of care acts.

This macro-process could be broken down into four main stages:

Indication and therapeutic planning	Where diagnosis, stage, biomarkers, treatment line, clinical objective and patient conditions are connected.
Treatment validation and preparation	This involves clinical review, pharmaceutical validation, nursing assessment, analysis, dosage, preparation, and traceability.
Outpatient administration	This is where the treatment takes place, but where risks of identification, access, monitoring, incidents, and registration are also concentrated.
Monitoring, toxicity, and continuity	Where what happens between cycles is woven together: the symptoms, the emergencies, the adjustments, the suspensions, the response evaluation and the next therapeutic decision.

The key is that these moments don't operate independently. Security and efficiency depend precisely on how they are connected.

A sound medical decision can lose its effectiveness if the process does not ensure adequate validation, preparation, administration, monitoring, and reassessment. Similarly, a well-organized process should be designed to facilitate better clinical decisions, not merely to move patients through a circuit.

A lesson for our healthcare systems

Ireland's experience should not be interpreted as a model to be copied verbatim. Every healthcare system has its own structure, resources, networks, and organizational methods. However, it does offer a clear lesson: the proliferation of cancer treatments necessitates a reorganization of the systemic therapeutic phase based on a continuum of care.

The oncology and hematology day hospital remains an essential component, but it can no longer be the sole conceptual reference point. What matters is not only where treatment is administered, but also how the entire set of clinical, pharmaceutical, nursing, logistical, and organizational decisions that support the patient throughout the therapeutic phase are managed.

In a context of increasing clinical complexity, therapeutic innovation requires organizational innovation. And that innovation involves understanding outpatient systemic antineoplastic treatment as a critical segment of the oncology care continuum.

Breast cancer clearly illustrates this need. Its management requires coordinating diagnostic, therapeutic, and follow-up decisions over extended periods, involving multiple professionals and increasingly specific therapeutic options. In these types of processes, the value lies not only in each individual intervention, but also in the system's ability to connect them.

Conclusion

International experiences based on SACT show that the future of cancer care lies not only in having more treatments available, but in better organizing the process in which those treatments are indicated, prepared, administered, monitored and reassessed.

Ireland teaches that systemic cancer treatment can be approached as a model of care: with governance, safety, protocols, care network, shared information and continuity.

The question, therefore, is not just how many therapeutic options a healthcare system incorporates. The question is whether that system is prepared to adequately manage the continuum of care that these therapeutic options require and to support increasingly complex medical decisions at each stage of the process.