LAUSR

The current financial crisis has particularly affected health care delivery in Greece, which is experiencing severe economic hardship and political turmoil since 2008. Applied fiscal-control centered policies and reductions in public expenditures have decreased the extent and the quality of medical services provided by the Greek National Health Care System (Ε.Σ.Υ.) in many diverse areas including respiratory medicine. Therefore, in these “tumultuous times” it seems especially challenging to maintain the delivery of quality lung cancer care to patients. However, wanting to improve existing lung cancer surgery provision in the region of coverage of the 2nd Sanitary Region of Piraeus and the Aegean, a large catchment area with over 1,038,359 residents (2011 census) which includes the large underdeveloped, low socioeconomic region of West Attika, in which a high smoking prevalence and industrial facilities’ exposure produces an annual incidence of lung malignancy of over 14.2%, a new academic thoracic surgery department was created at “Attikon” University Hospital. This is a 730-bed hospital of the National and Kapodistrian University of Athens, a centrally located tertiary care facility which naturally also acts as a referral center for patients from all over Greece. From the beginning there was a conscious decision and effort made in providing the best possible clinical care based on internationally established protocols for pre-operative assessment and perioperative management of all thoracic patients. Therefore, the department currently complies with all the recommended structural characteristics and organizational parameters of a general thoracic surgery unit, proposed by the European Association for CardioThoracic Surgery (EACTS) and the European Society of Thoracic Surgeons (ESTS), except from the 24-hour exposure to trauma. Hence, a once a week multidisciplinary lung oncology team meetingwas instigated comprised of a pulmonologist, onemedical, and one radiation oncologist, an oncology associate, a histopathologist, a dedicated nurse, and the thoracic surgery team. Coordinated by the lead thoracic surgeon and the medical oncologist it focuses on assessing all referred lung cancer patients’ suitability for surgical resection and planning the delivery of appropriate anticancer treatments according to National and International guidelines. The team is supported by an excellent pain management unit and a pathology and cytology team engaged in the immuno-histochemical (Programmed Death Ligand-1), genomic, and molecular profiling of lung cancer (such as EGFR and ALK). Consequently, patients with advanced stage disease are now referred “in-house” for targeted therapy, neo-adjuvant chemotherapy or combined chemo-radiation therapy, and if subsequently down-staged they undergo surgical resection. Accordingly, based on post-operative histopathological outcomes, operated patients undergo appropriate adjuvant treatment. Over the last 2 years, from February 2015 when services were commenced and until April 2017, this new department has become quite prolific providing modern lung cancer care and surgery to the region and beyond despite the fiscal limitations imposed to the Greek national healthcare system by the monetary crisis. A total of 178 (43% of total) primary lung cancer resections (lobectomies and pneumonectomies) have been performed with excellent overall clinical outcomes, and over 900 new and follow up patient consultations have been conducted in outpatient clinic, while continuous “in-hospital” thoracic surgery support has been provided to respiratory medicine and other medical and surgical specialties. Initially, conventional open thoracic surgery was performed but over the last fourmonths andwith the additional support provided by a newly appointed locum consultant a video-thoracoscopic (VATS) resection program was instigated offering minimally invasive surgery to all eligible thoracic patients. A dedicated VATS theater day once a week with three scheduled cases was allotted. Therefore nowadays, when applicable, lung nodule biopsies, segmentectomies, bullectomies and metastasectomies are performed by VATS. Recently, we started building up our experience with more extensive resections (Figure 1 a photo of the surgical team during our first VATS lobectomy). In addition, the need to operate on sicker patients, with an increased risk if general anesthesia is used led to the initiation of a case series of