DHMA strives to ensure consistent planning, coordination, and collaboration between relevant parties in the Danish healthcare system, thereby ensuring that specialized treatment can be provided nationally with the necessary capacity and timely due availability.
Link to DHMA Specialized Hospital Services for all publicity funded hospital services in Denmark (in danish)
The DHMA Specialty plan (2017) is based upon §208 of the Danish Health Care Act. It describes organization, management, and requirements for performing specialized functions at public re-gional and private hospitals. DHMA ma - specialized hospital serviendates/approves individual hospitals to provide specific specialized services and has the statutory authority to discontinue specialized services and with-draw approvals for the performance of specialized services at public/private hospitals. DHMA is responsible for performing regular reews to ensure planning of specialized hospital services is up-to-date, relevant, and adequate.
Specialty guidance documents for 35 medical and 1 odontological, specialties are maintained and updated by DHMA. These documents define specialized hospital service within the special-ties and lists the approved hospitals for each specialized service. These 36 documents consti-tute the national plan for specialized hospital services and aim to ensure quality and continuity of patient care, while simultaneously ensuring efficient resource utilization.
Note: The Danish public healthcare system is widely based upon national laws, guidelines, cancer-packages, collaboration agreements etc. Legally binding contracts and formalized accreditation procedures within the Danish public healthcare system are usually not executed or performed in Denmark – which is rather different compared to many other European countries.
Clinical oncology is a specialized hospital service area and described in detail in the Specialist Guidance for Clinical Oncology (of February 14th, 2023 (https://www.sst.dk/-/media/Viden/Spe-cialplaner/Specialeplan-for-klinisk-onkologi/Specialevejledning-for-Klinisk-onkologi-den-14-feb-ruar-2023-_D10161955_.ashx). Clinical Oncology entails prevention, diagnostics, non-surgicaltreatment, care, palliation, and rehabilitation of patients with cancer-diseases in all organ-sys-tems. The specialty further entails research, development, and education within areas of the spe-cialty.
Core tasks
The core tasks within clinical oncology are acute and elective diagnostics, as well as treatment and care for patients with malignant diseases. The treatment modalities within the specialty in-clude both medical treatment (chemotherapy, hormonal therapy, targeted biological treatment, immunotherapy) supportive care, palliative treatment terminal care), and radiotherapy.
For the specialty of clinical oncology there are broad collaborations with specialties in the hospi-tals on diagnostics, staging, post-treatment follow-up, monitoring of adverse effects and pallia-tion. The collaborations are organized around Multi-Disciplinary-Teams (MDT) with regular com-mon conferences.
Fast track referral programs (“cancer-packages”)
In Denmark we have fast track referral programs (“cancer-packages”) to enable and ensure pro-fessional and timely diagnostics and treatment of patients with cancer. They are in effect in all Regions of Denmark and are initiated by doctors upon reasonable suspicion of various cancer types. Standardized and prioritized referral of patients (often to surgical departments) for inves-tigations, tests and evaluations are designed and functioning to effectively determine, if a patient has cancer or not (https://www.sst.dk/da/sygdom-og-behandling/kraeft/pakkeforloeb).
The Comprehensive Cancer Centre of Copenhagen (CCCC)
CCCC is in the Capital Region of Denmark and consists of 2 collaborating highly specialized clinical oncological departments, from Rigshospitalet and Herlev-Gentofte-Hospital respectively, who combined constitute a comprehensive cancer center. The cancer center manages cancer dis-eases in all organ-systems.
Collaborative surgical departments for cancer treatment
It is essential to ensure high-quality surgical cancer treatment across departments, hospitals, and regions. Each department performing cancer surgery must continuously work to maintain and fur-ther improve surgical competencies.
Post-cancer-surgery evaluations are performed either in the surgical departments, in decentral-ized (local) surgical departments, or in surgical outpatient clinics. Individually detailed patient fol-low-up programs may allow follow-up evaluations to be performed in general practices. General physicians must refer patients back for specialist evaluation, when indicated.
Surgical departments for the various specialties perform acute and elective diagnostics, treat-ment, and care of patients with both benign and malignant diseases. For patients diagnosed with cancer, the recommended initial treatment of choice can be either surgical or oncological. The surgical treatments include open/laparoscopic/robot-assisted surgery, minimally invasive tech-niques, as well as endoscopic procedures. Below we will focus only on malignant diseases.
Surgical treatment of malignant diseases is often complex, and several professionals may partic-ipate in performing the complete surgical procedure. Pre-surgical/pre-treatment MDT-confer-ences are essential for optimal and multidisciplinary evaluation during the clinical decision-making process.
Increased demand, for more individualized treatment strategies (surgical and oncological) for can-cer patients, are requested. The diverse and necessary competencies for high quality cancer treatment often warrant a supply of specialist doctors including surgeons, radiologist, pathologists, geneticists, and clinical oncologist, as well as skilled specialist nurses at each treat-ing facility.
Focus on improved/optimized pre-surgical and postoperative patient care, treatment and reha-bilitation will expectedly reduce morbidity/mortality after cancer surgery. In support hereof, it is essential to prioritize further research and quality evaluation/improvement of physician and nurs-ing competencies. Clinical guidelines (national and international) are available for treatment of cancer diseases, and future high-quality research will in time increase the underlying evidence for the guidelines at hand.
The Danish hospital system
Requirements for performing surgical specialized function
Published in 2015, the DHAM rapport (https://www.sst.dk/-/media/Udgivelser/2015/Special-ity-planning---concepts-principles-and-requirements.ashx) describes preconditions and require-ments for e.g., capacity and research, which any department must fulfil, to perform various spe-cialized functions. These requirements form the basis, however more specific requirements apply to the surgical departments as well.
Cancer surgery must be performed according to updated and relevant clinical guidelines (DMCG, Danish Multidisciplinary Cancer Groups). There must be continuous elaboration and further devel-opment of the surgical functions and guidelines. The department/hospital must ensure the nec-essary preparedness, sufficient robustness, experience, as well as surgical volume for both sur-geons and the team.
The National Board of Health continuously monitors the current specialty plan, ensuring it is up-to-date, relevant, and comprehensive. This is done through annual status reports to determine if it meets the requirements for the specialized functions.
The cancer diseases/diagnoses incl. diagnostic and therapeutic methods are listed below ac-cording to DMHA recommendations for handling in the Danish healthcare system.
The handling levels are described as below:
- Local (main) function level
- Regional function or
- Highly specialized level.
1. Recommendations for main surgical function level
Main surgical functions include investigations and treatment of various diseases and conditions, where patient care is of limited complexity. If an initiated investigation at this level gives reason-able suspicion, that the patient should be managed at the regional function or highly specialized level, the patient must be referred to a hospital approved for this purpose.
2. Requirements for performing regional functions and approved locations
Recommendations given for the main function level apply for the regional function level as well. Regional specialized hospital services are tasks of some complexity, the disease in question is relatively rare, or the services of the healthcare system are rarely required.
Furthermore, at regional function level, immediate assistance from a specialized surgeon must be available. Collaboration with other relevant specialties, on relevant level of specialization, must be present.
Regional surgical functions for malignant diseases are described here: https://www.sst.dk/-/me-dia/Viden/Specialplaner/Specialeplan-for-kirurgi/ Specialevejledning-for-Kirurgi-den-15-marts-2023.ashx.
The following surgical functions are examples of procedures for malignant diseases, and the ap-proved regional hospitals in DK, for performing them.
Esophageal cancer
2A. Installation of stents in the esophagus, including self-expanding metallic stents (SEMS) (250 patients). Stent placement with a palliative aim can possibly be performed at the main function level in formalized cooperation with the regional function level.
Carried out in close collaboration with internal medicine: gastroenterology-hepatology and clinical oncology
- Rigshospitalet, Blegdamsvej
- North Zealand Hospital - Hillerød (in formalized collaboration)
- Aarhus University Hospital
- Aalborg UH South
- Zealand University Hospital, Køge
- OUH Odense University Hospital
Rectum – and anal cancers
2B. Endoscopic procedures with removal of larger broad-based tumors e.g., TEM and EMR pro-cedures
- Bispebjerg and Frederiksberg Hospital, Bispebjerg (not TEM)
- Herlev and Gentofte Hospital, Herlev
- Amager and Hvidovre Hospital, Hvidovre
- North Zealand Hospital - Hillerød (not TEM)
- Aarhus University Hospital
- Herning Regional Hospital
- Randers Regional Hospital (in formalized collaboration) (not TEM)
- Aalborg UH South
- Zealand University Hospital, Køge
- OUH Svendborg Hospital
- Lillebælt Hospital, Vejle (in formalized collaboration) (not TEM)
Malignancies in Spleen
2C. Spleenektomi, haematological Spleen.
Carried out in close collaboration with internal medicine: Heamatology
- Rigshospitalet, Blegdamsvej
- Herlev and Gentofte Hospital, Herlev
- Aarhus University Hospital
- Aalborg UH South
- Zealand University Hospital, Køge
- OUH Odense University Hospital
- Breast cancer
2D. Oncological breast surgery without the need for reconstruction.
Carried out in a multidisciplinary team with common guidelines and common conferences accord-ing to standardized treatment regimens (“Cancer packages”)
- Herlev and Gentofte Hospital, Herlev
- Aarhus University Hospital
- Randers Regional Hospital (in formalized collaboration)
- Viborg Regional Hospital
- Aalborg UH South
- Regional Hospital North Jutland, Hjørring (in formalized cooperation)
- Zealand University Hospital, Roskilde
- OUH Odense University Hospital
- Lillebælt Hospital, Vejle
- Hospital Southwest Jutland, Esbjerg
- Hospital Sønderjylland, Aabenraa
Breast cancer
2E. Oncological breast surgery in need of primary reconstruction as well as in need of major onco-plasty (see DBCG, Danish Breast Cancer Group, clinical guidelines), including patch techniques with patches retrieved outside the chest, as well as major displacement or volume reduction techniques; the latter techniques depending on the expertise of the breast surgery department and by local agreement (500 pt. per year).
Carried out in a multidisciplinary team with common guidelines and common conferences accord-ing to standardized treatment regimens (“cancer packages”)
- Herlev and Gentofte Hospital, Herlev
- Aarhus University Hospital
- Aalborg UH South
- OUH Odense University Hospital
- Lillebælt Hospital, Vejle
- Hospital Southwest Jutland, Esbjerg
- Hospital Sønderjylland, Aabenraa
3. Requirements for performing highly specialized functions
The requirements listed for the regional function level also apply to the highly specialized level.
At the highly specialized level, it must be possible to obtain the assistance of a specialist in sur-gery immediately. For maintaining a highly specialized level in surgery, collaborations with other relevant specialties at the relevant level of specialization are mandatory.
Highly specialized surgical functions for malignant diseases are described here: https://www.sst.dk/-/media/Viden/Specialplaner/Specialeplan-for-kirurgi/ Specialevejledning-for-Kirurgi-den-15-marts-2023.ashx.
The following surgical functions are examples of procedures for malignant diseases, and the ap-proved highly specialized hospitals in DK, for performing them.
Cancer of the esophagus and stomach
3A. Oesophagus, cardiac and gastric cancer, and premalignant conditions therein, including endo-scopic submucosal dissection in the esophagus and ventricle.
Carried out in a multidisciplinary team with common guidelines and common conferences accord-ing to standardized treatment regimens (“cancer packages”)
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
- Aalborg UH South (in formalized collaboration)
- OUH Odense University Hospital
Rectum - and anal cancer
3B. Advanced pelvic surgery for intestinal tumors, including: (1) Local advanced primary rectal cancer (phrased local growth in bladder top or uterus) (approx. 40 pt./year), (2) Intended curative surgery for local recurrence of rectal cancer and metastases (also in the same area) (approx. 20- 25 pt./year)
- Herlev and Gentofte Hospital, Herlev
- Aarhus University Hospital
3C. Surgery for anal cancer (20 pt.).
Carried out in a multidisciplinary team with common guidelines and joint conferences according to standardized treatment regimens (“cancer packages”)
- Herlev and Gentofte Hospital, Herlev
- Aarhus University Hospital
Malignancies in abdominal wall, peritoneum, mesentery, and omentum
4A. Peritonectomy in peritoneal carcinosis with HIPEC (Hyperthermic intraperitoneal chemother-apy) (25-30 pt.)
- Aarhus University Hospital
4B. Surgical treatment of retroperitoneal and intra-abdominal sarcomas.
Cared for in one multidisciplinary team with common guidelines and common conferences ac-cording to standardized treatment regimens (“cancer packages”)
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
Malignancies in Liver and bile ducts
5A. Primary tumors in liver, where surgical, ablative, or medical treatment is considered (50-100 pt.) Carried out in a multidisciplinary team with common guidelines and common conferences according to standardized treatment regimens (“cancer packages”)
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
- OUH Odense University Hospital
5B. Central bile duct tumors (20 pt.).
Carried out in a multidisciplinary team with common guidelines and common conferences
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
5C. Local treatment (resection/ablation) of liver metastases, gallbladder cancer, peripheral bile duct cancer and benign liver tumors (600 procedures / year).
Cared for in one multidisciplinary team with common guidelines and common conferences ac-cording to standardized treatment regimens (“cancer packages”)
- Rigshospitalet, Blegdamsvej
- Herlev and Gentofte Hospital, Herlev (in formalized collaboration) (ablation only)
- Aarhus University Hospital
- Aalborg UH Syd (in formalized collaboration)
- OUH Odense University Hospital
5D. Liver transplantation (60 procedures / year).
Carried out in close collaboration with internal medicine: Gastroenterology and hepatology
- Rigshospitalet, Blegdamsvej
5E. Bile duct disorders and iatrogenic bile duct injuries in need of reconstructive surgery (biliodi-gestive anastomoses) (50 pt.). Reconstructive surgical treatment does not include acute resto-ration of minor per-operative damage to the bile ducts
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
- OUH Odense University Hospital
Malignancies in Pancreas (300 pt.) and duodenum
6A. Resection of benign and malignant pancreatic tumors including periampullary and duodenal cancers (4-500 procedures/year).
Carried out in close collaboration with internal medicine: Gastroenterology and hepatology
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
- Aalborg UH South (in formalized collaboration)
- OUH Odense University Hospital
6B. Surgery for neuroendocrine tumors (60 pt.).
Carried out in collaboration with relevant specialties
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital
- OUH Odense University Hospital
Cancer in breast
7A. Surgery for breast cancer with growth in the thoracic wall (10-20 pt.).
Carried out in close cooperation with plastic surgery and thoracic surgery
- Rigshospitalet, Blegdamsvej
- Aarhus University Hospital