One of the network’s main goals is to introduce indicators specific to particular disease entities for use in monitoring the quality of services provided within oncological care. The proposed system is rooted in a mechanism that enables constant improvement under a plan-do-check-act (PDCA) cycle.

The data suggest a correlation between the quality of the medical process, its organisation, and the therapeutic effect [7,8,9,10]. Moreover, an idea of quality indicators in oncology is introduced in different areas of cancer care [11,12,13]. Until now, Poland has had no unified system for managing a large database containing data on cancer patients, which would make it possible to use such data to calculate indicators related to outcomes and internal processes, i.e. the quality of individual hospitals that provide oncological care. The pilot project for the network is meant to test the functioning of specially designed data warehouses, the quality of data stored in these warehouses, the process of collecting the data, and the flow of data between individual components in the network.

When the NCN was being designed, emphasis was placed on creating a unified data structure for all centres participating in the pilot project and on automating processes (e.g.the calculation of individual indicators) to the greatest extent possible. This was done to facilitate and accelerate data processing. In addition, these assumptions meant that the obtained results could be expected to be reliable and transparent and to enable easy comparison between centres or provinces.

The purpose of monitoring oncological care processes is to identify areas that require an increase in quality level or that should be maintained at a specified satisfactory level. Our analysis showed that the results obtained through the NCN indeed identified such areas. Of the 21 indicators, two were at an unsatisfactory level compared to values specified as target values. For ‘Percentage of patients with stage 3 non-small-cell lung cancer who received concurrent chemoradiotherapy’, the obtained result was only 6%. Similar analyses conducted in other European countries revealed a higher percentage of administration of this treatment regimen [14, 15]. Such low results in our province may be related to the different structures of patients with stage 3 cancer included in our analysis. It is possible that the vast majority of patients were stage 3B and 3C patients, who are more commonly qualified for sequential chemoradiotherapy. However, the definition of the indicator failed to differentiate between stages 3A, 3B, and 3C. Another reason for the unsatisfactory outcome may have been organisational or logistical obstacles. Even in Wroclaw, the capital of the province, hospitals that provide systemic treatment for lung cancer patients and the facilities that provide radiation therapy are located in different parts of the city, which could have affected the choice of treatment regimen and led to a preference for sequential therapy. It is also possible that there was a methodological error that affected the reliability of the findings. Further studies are needed to either confirm the above reasoning or to identify other factors that influence the result obtained for the indicator in question. Such internal analysis is currently being conducted by the Regional Coordination Centre.

Increasing the number of patients qualified for concurrent treatment seems vital given the current indications for immunotherapy, which in this instance led to an increase in the overall survival rate in patients who received concurrent chemoradiotherapy [16, 17].

The second outcome, which fell significantly below the set standard, was the very low percentage of lung cancer patients with a diagnosis of pleural effusion at only 8%. Of the 25 patients included in the assessment through this indicator (‘Percentage of patients with suspected lung cancer and pleural effusion in whom aetiology of the effusion was identified’), only 2 received such a diagnosis. However, this indicator received negative opinions from experts who approved it in Lower Silesia Province and will likely not be included in the NCN after the pilot project ends.

One argument supporting the exclusion of this indicator is its doubtful function in the clinical realm. Pleural effusion is typically seen in palliative care patients, for whom delaying symptomatic treatment due to commencement of a pleural effusion diagnosis seems unacceptable.

Furthermore, the number of included patients for this indicator was very low at only 25. The same was true for ‘Percentage of patients with suspected lung cancer seen by a pulmonary specialist within 14 working days of registering a referral with the health care provider’ at only 62 patients. This may have been caused by incorrect design of the indicators and the lack of information concerning the described event (such as being seen by a pulmonary specialist) in the patient’s medical history, which makes it impossible to correctly assign the patient within the indicator in question. This indicator may also be rejected following the conclusion of the pilot project according to the reasons stated above.

Analysis of the results obtained through the NCN for our province also identified indicators that met their target values or were very close. Two of these described the patients’ condition. The first measured the share of patients who required hospitalisation due to complications following the conclusion of radiation therapy for cancer and had a value of 0% at the end of the assessed period. The second evaluated the number of patients who required hospitalisation due to complications following systemic treatment. In this case, the data concerned the periods of 30, 60, and 90 days after the assessed therapy ended. A result of 2% was obtained for each period. When compared to similar analyses, the obtained outcomes may be regarded as indicating that the frequency of complications requiring hospitalisation following non-surgical treatment in our region is optimal [18, 19].

We believe, however, that the introduction of an additional indicator—which would make it possible to assess the number of hospitalisations required during radiation therapy administered primarily on an outpatient basis—should be considered. Other new indicators could also be included in the NCN, e.g. indicators evaluating aspects related to immunotherapy or stereotactic radiation therapy for lung cancer.

Another group of indicators that met the levels expected under the assumptions of the NCN involves diagnostic procedures. These indicators describe internal processes and the quality of specific procedures. Therefore, the percentage of imaging, endoscopic, and molecular procedures that required reimpression or reassessment or were repeated within a 6 week-period was 0%. This outcome reflects the high quality of initial and follow-up diagnostic procedures for lung cancer in centres that form a part of the NCN in the analysed region of Poland.

It is worth referring to an analysis of tests performed for genetic and molecular predictors in patients at clinical stages 3 and 4 and the epidemiological structure of this group of patients. Compared to the findings presented in that analysis, which cover the NCN’s period of functioning between 2019 and 2020 in Lower Silesia Province, the current study showed no significant differences in the scope of the analysed aspects [20]. Only the percentage of stage 3 patients who underwent an assessment of predictors decreased, from 40% at the end of 2020 to 35% at the end of 2021.

A significant disproportion between the number of lung cancer patients reported by individual centres is noticeable. It stems from the specific nature of the organisation of health care related to pulmonary diseases in Lower Silesia Province. As many as 73% of patients included in the pilot project for the NCN were reported by a single centre, the Lower Silesia Centre for Pulmonary Diseases in Wroclaw. This unit has been the primary centre for the treatment of pulmonary diseases in our region for many years, which explains the high number of patients reported by it among those included in the pilot project.

From the perspective of the idea of the project, a sufficiently high level of inclusion of patients in the network is essential. Leaving patients out of the network leads to results that may provide an inadequate picture of the current situation as assessed by a particular indicator. Likewise, consistent reporting of patients by the same centre or within the same province is key with respect to the reliability of the outcomes. In our analysis, we noticed differences in the number of reported clinical stage 3 patients for two indicators: the statistical indicator that evaluated the percentage of stage 3 patients encompassed 890 patients, while the indicator that assessed the share of patients in the same stage who received concurrent chemoradiotherapy had only 516 patients. The cause of this difference can be traced to different definitions of indicators and criteria for inclusion. It also seems likely that, simultaneously, there may have been errors in reporting caused by imprecise information contained, e.g. in medical histories of patients included in the pilot project or by patients ‘escaping’ the NCN due to errors in the data management process, which was not automated.

It is clear that working with such a large database concerning cancer patients requires many years of observation. This condition allows us to assume that it will be possible to correlate results obtained through the NCN during its operation for individual types of malignancies with direct treatment effects, expressed through a local control group or the overall survival rate. Furthermore, identifying such correlations will make it possible in the future to modify specific steps of oncological care and thus create conditions to improve the effectiveness of cancer treatment in a given area. Adopting the NCN concept into the Polish oncological care system would create an opportunity.

At the moment, it is difficult to compare the outcomes obtained and presented in this paper with the period before the pilot project was implemented for the NCN, as Poland had no similar system for quality assessment in oncology in place.

This paper presents findings on a selective basis, concentrating on the analysis of indicators related to lung cancer diagnosis and treatment. Other components of the NCN—such as the creation of the position of Coordinator for Oncological Care; measurement of the level of satisfaction with health care, assessed by the patient using a dedicated survey; or standardisation of reports from pathological and radiological exams—require further, separate analyses.

The limitation of the presented work is the pilot nature of the project. Errors in data reporting, incomplete data, and elements of the NCN, such as the aforementioned measures that do not fulfill the intended role, are some of the limitations of the pilot.

We believe that the ongoing pilot project for the NCN, understood as a platform for testing the NCN’s components, will make it possible to identify significant limitations; once these are eliminated, we can take advantage of the potential stemming from coordinated and high-quality oncological care.