Chirurgie du cancer et qualité des soins, encore un effort !

FlickR - Cellules cancéreuses du sein - crafty_dameCela aurait pu s’appeler « Comment le journal Le Parisien a coupé l’herbe sous le pied du magazine Le Point ». Pour établir son palmarès dès aujourd’hui, le premier a confié le travail à la société Santéclair qui s’est appuyée sur des données publiques relatives aux seuils d’activité. Pris de court, le second a préféré, dans le cadre d’une démarche un peu plus « scientifique », demander aux établissements de santé par courrier une copie de leur autorisation en cancérologie. L’autorisation sanitaire étant une décision administrative émanant des autorités sanitaires à l’échelon régional, elle est publiée dans le recueil des actes administratifs des préfectures de département et de la préfecture de région, donc facilement disponible, pour peu que l’on dispose d’un ordinateur et d’une bon débit de connection Internet.

Le Parisien a donc établi le palmarès des hôpitaux et cliniques de France pratiquant la cancérologie, ainsi que le palmarès des établissements parisiens spécialisés dans cette discipline. Si imparfait soit-il, un classement comporte toujours des enseignements. Et le présent classement, dont la presse locale (la Dépêche, Aujourd’hui, AuFéminin.com, etc.) et les blogs (celui de Jean-Daniel Flaysakier, par exemple) se sont largement fait l’écho depuis ces dernières 24 heures, nous enseigne que deux établissements sur trois pratiquant la chirurgie du cancer du sein ne se trouvent pas dans le palmarès, faute de pouvoir justifier d’une activité suffisamment significative ou de bons résultats de certification. Au total, c’est un établissement sur deux qui ne se trouve pas dans ce palmarès.

Quatre types de tumeurs ont fait l’objet de ce classement : la tumeur du sein, celle de l’appareil digestif, de la prostate et de la sphère ORL.

C’est toujours le même principe (de bon sens) : plus on pratique, mieux on pratique.

Quelques explications s’imposent.

Comme toute activité faisant l’objet d’une autorisation (médecine, chirurgie, obstétrique, soins de suite et de réadaptation, etc.), l’activité de traitement du cancer a fait l’objet d’une réglementation au sein du code de la santé publique. Il s’agit en l’occurrence du décret n°2007-388 du 21 mars 2007 relatif aux conditions d’implantation y afférentes. Ce décret comporte, en son article 3, des dispositions transitoires. Et c’est là que le bât blesse. En effet :

« Pendant la période de dépôt des demandes d’autorisation ouverte, conformément à l’article R. 6122-29 du code de la santé publique, dans les deux mois suivant la publication des dispositions du schéma d’organisation sanitaire mentionné à l’article 2, les établissements de santé ou les groupements de coopération sanitaire ou les personnes qui, à la date de publication du présent décret, exercent l’activité de soins mentionnée au 18° de l’article R. 6122-25 du code de la santé publique doivent demander l’autorisation prévue à l’article R. 6123-86 du même code. Les demandeurs peuvent poursuivre leurs activités jusqu’à ce qu’il soit statué sur leur demande dans les conditions prévues à l’article L. 6122-9 du même code.

Sous réserve que soient remplies les conditions prévues aux 1° et 2° de l’article L. 6122-2 du code de la santé publique, cette autorisation leur est accordée aux conditions suivantes :

1° Attester au moment de la décision de l’agence régionale de l’hospitalisation d’une activité minimale annuelle réalisée au moins égale à 80 % de l’activité minimale annuelle qui leur est applicable, établie conformément aux dispositions de l’article R. 6123-89 du même code ;
2° Respecter les dispositions transitoires suivantes :

a) Remplir, dans un délai de dix-huit mois à compter de la date de réception de la notification de l’autorisation, les conditions d’activité minimale annuelle fixées conformément aux dispositions de l’article R. 6123-89 susmentionné, qui leur sont applicables ;
b) Se mettre en conformité, dans le même délai, avec les dispositions des articles R. 6123-87 à R. 6123-95 du code de la santé publique ainsi qu’avec les conditions techniques de fonctionnement fixées en application de l’article L. 6124-1 du même code ;
c) Lorsque l’autorisation est accordée à titre dérogatoire en vertu des dispositions du deuxième alinéa de l’article R. 6123-93 du code précité, se mettre en conformité, dans un délai de trente-six mois à compter de la date de réception de la notification de l’autorisation, avec les conditions prévues au dernier alinéa du même article.

Lorsqu’à l’expiration de ces délais, il est constaté que l’établissement de santé ou le groupement de coopération sanitaire n’est pas en conformité avec les dispositions du code de la santé publique mentionnées au 2° du présent article, l’autorisation fait l’objet des mesures prévues à l’article L. 6122-13 du code de la santé publique ».

Or, l’arrêté d’application du décret, à savoir l’arrêté du 29 mars 2007, fixe les seuils d’activité minimale annuelle applicables à l’activité de soins de traitement du cancer. La méthode de calcul des seuils d’activité a été définie au sein de la circulaire DHOS/INCA du 26 mars 2008.

Un peu à l’image des projets d’arrêtés relatifs aux seuils d’activité en médecine et en chirurgie, le compte à rebours pour les établissements pratiquant la chirurgie des cancers, la radiothérapie externe et la chimiothérapie, a inexorablement commencé. Dans un délai somme toute assez bref, ils sont sommés de monter puissamment en charge pour espérer conserver leur autorisation. Il y a fort à parier que ceux qui vont disparaître permettront un formidable appel d’air pour les établissements déjà positionnés dans cette discipline.

Quoi qu’il en soit, il est désormais inacceptable qu’un établissement pratique cette spécialité avec un seul praticien qui décide tout seul dans son coin de la stratégie à adopter pour lutter contre le cancer de ses patients. Les réunions de concertation pluridisciplinaire (oncologues, chirurgiens, gériatres, etc.) ont largement démontré, s’il en était encore besoin, leurs vertus.

En somme, il faut grossir ou périr.

Plus d’informations sur le site de l’Institut national du cancer.

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