Regarding cancer prevention, educational activities are organized by the MoH in collaboration often with patients’ organizations and advocacy groups. A smoking cessation clinic operates in Nicosia General Hospital with plans to set up similar clinics in all general hospitals.

Regarding screening activities, a comprehensive national breast cancer screening programme has been in place since 2007, which is free for all women between the ages of 50 and 69 years [7]. There is no formal comprehensive screening for cervical, colorectal, and prostate cancer in Cyprus , instead individuals present themselves to their physicians either for other reasons (opportunistic screening) or specifically to request screening. The high prostate cancer incidence in Cyprus (see Table 11.2) suggests that the practice of PSA testing is widespread. A pilot programme for colorectal cancer screening has been recently initiated. Finally in terms of cervical screening, health surveys from 2003 to 2008 suggest that there is a reduction in the percentage of women undergoing pap tests; 80.9 % of women surveyed in 2003 had a pap test compared to 73 % in 2008 [7, 11, 12].

Genetic testing is available for hereditary predisposition and familial cancer syndromes especially in relation to Breast and Colon cancer in the Cyprus Institute of Neurology and Genetics [13].

Treatment of all patients with cancer is provided in the two public/government oncology units, located in the Nicosia and Limassol General hospitals and also in the Bank of Cyprus Oncology Centre (BOCOC) . The BOCOC is a not-for-profit organization, co-founded and co-funded by the Bank of Cyprus and the Cyprus Government, and is the only purpose built Oncology tertiary referral centre in Cyprus [14]. The BOCOC essentially operates as a public oncology centre, accepting all patients eligible for health care in Cyprus without charging patients any additional fees (over and above those charged in the public hospitals). The BOCOC provides comprehensive specialized nonsurgical oncology services, including both Chemotherapy and Radiotherapy, whilst the public hospitals oncology units provide only chemotherapy. In terms of radiotherapy facilities the BOCOC is equipped with three linear accelerators, with Image Guided and Intensity Modulated Radiotherapy as well as Stereotactic Radiotherapy capabilities, a superficial orthovoltage treatment unit and a High Dose Rate (HDR) Brachytherapy system. In terms of chemotherapy facilities, there is a day care unit for outpatient chemotherapy administration (19 beds), with a separate room for infusions with four couches and four chairs (for iv zoledronic acid and Trastuzumab). This is supported by an aseptic suite for the reconstitution of cytotoxic drugs, a pharmacy and dispensary. There is also a day care unit for supportive care (13 beds/couches) and two wards for hospitalization of patients with difficult-to-control symptoms and inpatient treatment with chemotherapy and radiotherapy (38 beds).

There is a limited number of private oncologists, based in private hospitals, which see and treat a small percentage of cancer patients, although often act as a source of second opinion for patients treated at the BOCOC or at the public hospitals oncology units. Of note that three medical schools have been set up in the last 4 years in Cyprus offering undergraduate medical courses (St George’s, University of London in association with the University of Nicosia, the University of Cyprus, and the European University). Although all are affiliated with local hospitals in Cyprus, none of the Medical Schools is involved in providing oncology services or has dedicated oncology facilities.

From the 2013 Annual report for the BOCOC it is stated that 2108 new patients were seen in 2013; and in total in excess of 26,000 patients were seen since its foundation in 1999 [15]. Furthermore in 2013 there were 34,449 outpatient clinic visits, 10,175 outpatient chemotherapy administrations with a further 2796 targeted therapies including zoledronic acid administrations, and 1540 inpatient chemotherapy administrations. From the Nicosia General Hospital (NGH) annual report for 2013, it is stated that there were 6084 outpatient visits at the NGH Oncology clinic compared to 7070 in 2012, with 2201 outpatient chemotherapy treatments provided [16]. At the Limassol General Hospital (LGH) Oncology unit in 2013, there were 593 new patients seen, 9396 outpatient clinic visits, and 3721 chemotherapy and other intravenous treatments [17].

In terms of radiotherapy activity, 32.251 fractions of external beam Linear Accelerator radiotherapy were delivered at the BOCOC in 2013, in addition to 192 brachytherapy treatments (predominantly for gynaecological cancers) and 1.271 fractions of superficial orthovoltage radiotherapy for skin malignancies [15]. There are currently no waiting lists for Radiotherapy treatment in Cyprus, as a result of the efficient use of the three Linear Accelerators, delivering each close to 11,000 fractions of external beam radiotherapy per year, whilst using the new advanced Radiotherapy techniques, including the use of Image Guided and Intensity Modulated Radiotherapy. This compares very favourably with recommendations from the UK, which suggest that for the UK the average number of fractions per linear accelerator should increase to 8700 fractions per linear accelerator per year by 2016 [18].

From the Cyprus Cancer Registry 2011 progress report covering 2006–2008 data [9], the number of patients registered at the different Oncology providers, i.e., the BOCOC/the General Hospitals and private hospitals, can be seen in Table 11.3.

In terms of geographical citing of oncology services, Nicosia is in the middle of the island, where both radiotherapy and chemotherapy services are available whilst Limassol is in the south and west of the island, with only chemotherapy services available. In terms of distances that patients have to travel to Nicosia, the furthest east town of Paralimni is 75–85 km away, in the south the town of Larnaca and Limassol are less than 70 km away, whilst the furthest away district by far is in the west of the island, Paphos, is around 120 km away (see Fig. 11.1, Map of Cyprus). Between all main towns in Cyprus (Nicosia, Larnaca, Limassol, Paphos, and Paralimni) there are new, modern, dual carriage motorways, allowing for both safe and fast travel between the main towns [2].

Palliative Care (PC) services in Cyprus are mainly provided by NGOs (Non-government Organizations), whilst there are currently no organized public PC services [1, 2, 19]. Furthermore these services provide almost exclusively to adult cancer patients, given that there are no organized paediatric PC services. Patients with other life-threatening but non-cancer related conditions, are rarely referred to these PC services [1, 2]. The main NGOs in the Republic of Cyprus are the Cyprus Anti-cancer Society (CACS) [20] and the Cyprus Association of Cancer Patients and Friends (PASYKAF) [21], which were founded in 1971 and 1986, respectively [2]. Both NGOs provide a home-based/specialist nurse delivered community-type PC service. The Cyprus Anti-cancer Society (CACS) also operates the main hospice in Cyprus, called Arodafnousa.

Both organizations have shared a major commitment for continuous training and education, and have encouraged their staff beyond attending training courses, also to work and attain higher degrees in PC [1, 2]. Through consistent training and education of PC staff, alongside their dedication to cancer patients in Cyprus, PC staff have been able to provide high quality service to cancer patients in Cyprus, both in the Arodafnousa hospice and in the community [2].

Beyond the CACS and PASYKAF, there are smaller NGOs, e.g., ELAZO which is the association for the patients of the Nicosia General Hospital, the “Friends of Life” Limassol, and “Friends of the Hospice” Paphos (run by expatriates from the UK) fundraising and helping with PC especially in the districts of Limassol and Paphos [2]. Supportive and PC, sometimes extending to end of life care, is also provided by the two Public Hospital Oncology Units in Nicosia and Limassol and by the BOCOC.

The main PC services provided across the Republic of Cyprus-controlled part of the island can be seen in Table 11.4.

In terms of PC specialists, there are currently only two physicians trained in PC in Cyprus; both work at the Arodafnousa hospice. Furthermore there is an oncologist with a diploma in Palliative Medicine, working in the Oncology Unit of the Limassol General Hospital. Finally there are also currently three physicians undergoing specialist PC training in a 3 year training program with the Institute of Palliative Care (formerly based in the San Diego Hospice, now in Ohio) in the USA; two of them work at the BOCOC and the other one works with the CACS in Limassol [2].

Other initiatives regarding PC in the BOCOC include since 2010, a weekly outpatient PC clinic being run by the two PC physicians from the CACS [2]. This helps both to improve patients’ difficult-to-control symptoms, but also encourages earlier introduction of PC in patients with advanced/metastatic cancer and facilitates referral of patients to the Arodafnousa hospice [2]. Furthermore, since 2012 with two physicians in the BOCOC receiving specialist training in PC, there has been the ability to form a hospital PC team and run daily a supportive/PC unit/drop in centre, to address urgent symptom control problems for cancer patients attending the BOCOC [2].

Regarding the availability of opioids in Cyprus, all four opioids on the WHO list are available, i.e., codeine, oral morphine immediate and controlled release forms and injectable morphine, whilst from the International Association for Hospice and Palliative Care (IAHPC) list there is also availability of fentanyl transdermal patches, methadone, and oxycodone long release preparations, whilst oxycodone immediate release is available, but patients in Cyprus have to pay for this [2, 22]. There is however no availability of buprenorphine and hydromorphone in Cyprus [2].

Examining the current legal framework in Cyprus for prescription of opiates compared to the guidelines for assessment of national opioid regulations of the World Health Organization [23], there is no significant overregulation for opioids in Cyprus; however, there is no legal framework to facilitate emergency prescribing and dispensing [2, 22].

In terms of opioid consumption for cancer patients in Cyprus, three studies examining physicians’ prescribing habits for cancer pain both within and outside the BOCOC undertaken in 2010 showed that only 56.0, 48.1, and 57.7 % of patients with pain were prescribed analgesia, with the majority of patients being prescribed paracetamol and nonsteroidal anti-inflammatory drugs, and, respectively, only 8.6, 11.5, and 0 % of patients being prescribed strong opioids [22]. In the last two studies, following their oncology appointment the prescription of analgesia to patients with pain increased to 80.8 % and 73.1 %, respectively, whilst the prescription of strong opioids to 28.8 and 34.6 %, reflecting oncologists’ practice within the BOCOC, hence providing evidence of an improvement in adequate pain management by oncologists within the BOCOC compared to pain management by general physicians in the community [22].

Of interest is the substantial increase (sevenfold) in the annual opioid consumption over the last 10 years in Cyprus, as can be seen in Table 11.5, expressed as total Morphine Equivalence (ME) in mg per person [24]. The last available data from 2012 from the Pain and Policy Studies Group of the University of Wisconsin is close to the global average of 61.7 mg/person.

Systematic high quality training courses in PC for Oncology and PC staff in Cyprus were initiated by the Middle East Cancer Consortium (MECC) [2]. MECC is an intergovernmental organisation, which was set up in 1996 by the governments of Cyprus, Egypt, Israel, Jordan, the Palestinian Authority, and the USA, through the National Cancer Institute of the United States of America [25]. The goal of MECC is to “raise cancer awareness in the Middle East and, ultimately, to reduce the burden of cancer in the region” [2]. MECC has been organising PC courses on an annual basis for health care professionals from its constituent members working in the Oncology or PC field with the first one taking place in 2004, in Larnaca, Cyprus, to which key members of staff from both NGOs, the BOCOC, and the General Hospitals’ Oncology Units over the years have participated. It is likely that this sevenfold increase in opioid consumption seen in the last 10 years (2003–2012), as well as general improvement in PC in Cyprus, at least partly reflects the impact of the work of MECC in promoting PC activities and providing training for health care professionals in Cyprus.

In terms of the four stages of development of PC (first stage is when no Services are identified, the second stage is that of Capacity Building, the third stage of Localized provision, and the final/fourth stage is that of Approaching Integration) it is currently accepted that Cyprus in terms of PC services is approaching integration [2, 26]. However further work needs to be done especially in providing organized PC within the main public hospitals, which is currently the main problem with PC in Cyprus [1, 2]. This results in patients in all the public hospitals having no input from specialist PC teams, and this applies both for cancer patients and for patients with other life-threatening illnesses, e.g. End stage Heart or Respiratory Failure [2]. Another main problem of PC services in Cyprus is that there is little cooperation between the two NGOs, resulting in a fragmented service, where currently each home care service only covers the patients at home between 8 am and 6 pm [1, 2, 19]. There are currently however efforts to unite the services of both CACS and PASYKAF, whilst a pilot program is currently being tried by PASYKAF to offer a true 24-h service in Limassol and subsequently in Nicosia, which is being facilitated by a European grant [27].

The financial crisis exposed the fundamental problem of the NGOs that their budgets and financial sustainability depends to a very large degree on donations and charitable contributions. The financial crisis by increasing unemployment and by negatively affecting peoples’ incomes resulted in reduced incomes for both the main NGOs, and as a result to a significant financial budget deficit for both of them. The contribution of the Government to both NGOs also decreased by a small amount. For the PASYKAF the 220,000 euros annual grant from the government was reduced by approximately 10 % to 195,000 euros, whilst for CACS the reduction was slightly less from 600,000 euros to 585,000 euros (in recognition of the costs to support the running of the Arodafnousa hospice).

To respond to decreased fundraising and the resultant budget deficit PASYKAF went ahead with a 16 % pay cuts for all its staff members in 2013 and 2014, but managed as a result to keep all services running. A similar proposal for pay cuts was however rejected by staff at CACS, hence as a result the Board of CACS, among other measures to decrease expenditure, had to lay off a small number of members of staff, with the resultant closure of three hospice beds in Arodafnousa and abolishing the home physiotherapy service, in 2013 [2]. However, with renewed enthusiasm new sources of funding were identified in 2014, and as a result new qualified nurses were recruited, hence currently the hospice operates its full capacity of 15 inpatient beds.

Also as a result of the current financial crisis in Cyprus, the two small hospice units in Limassol, at Chrysovalantou Clinic paid by the Friends of Life (Limassol) NGO, and in Paphos at the Evangelismos Hospital, funded by the Friends’ of the Paphos Hospice NGO, ceased to operate in 2013 [2]. Instead Friends for Life Limassol NGO is making a financial contribution to the CACS towards the running of the Arodafnousa Hospice, whilst Friends for Hospice in Paphos has managed to reopen a limited number (3) hospice inpatient beds in Paphos at the St Georges private clinic in 2014.

Finally, a new purpose built hospice, including facilities for children with cancer, Archangel Michael Hospice in Mesa Chorio village in Paphos is ready to start operating, awaiting final local authority approval [28]. Archangel Michael Hospice was planned to start operating in 2013; however, again due to the financial crisis there was a delay until sufficient funds were in place to ensure the smooth running of this facility in the future [2, 28].

Hence as a result of the financial crisis, there were only 12 inpatient hospice beds available in Cyprus in 2013, compared to 24 beds in 2011. Through hard work from all PC NGOs, and the set up of the completely purpose built hospice in Mesa Chorio, the capacity in 2015 is going to be 26 hospice beds (including two paediatric hospice beds in Archangel Michael hospice), which is clearly much better than in 2013 in the aftermath of the financial crisis and a little better than 2011, prior to the financial crisis (see Table 11.6). This is however still inadequate to cover the needs of a population close to one million, when compared with the European guidelines from the European Association of Palliative Care (EAPC) White Paper [29], where the original need for 50 PC care beds needed per million population has been upgraded to 80–100 beds per million population in view of the needs of non-cancer patients and the prevalence of chronic diseases due to the aging of the population [2].

As a result of the scarcity of inpatient hospice beds, patients with palliative care needs, including end of life care, who are unable to remain at home with home PC support, are often accommodated at the Oncology centres (BOCOC and the Oncology Units in Nicosia and Limassol General Hospitals), where they originally received their oncology treatment [2].

Until 2013 all services to cancer patients were free. In August 2013 legislation was enacted to introduce conditions for patients to be entitled access to cancer care and also to introduce nominal fees for patients whilst accessing this care. Under this legislation patients to be allowed access to cancer care have to fulfill the following two conditions: firstly to have paid for at least 3 years social security contributions and secondly to have filled in their tax return form at the time/year of seeking medical treatment. Furthermore a cap of 150,000 euros of family income was set to allow access to “free” cancer care, whilst patients with family income over this amount would have to pay for the full cost of their care. Furthermore, since 2013 cancer patients have now to pay a nominal fee of 6 euro to see an oncologist per outpatient visit (no fees for inpatient stays), and they also have to pay half a euro per drug/blood test prescribed. Charges for blood tests are waived when they undergo chemotherapy. Equally chemotherapy drugs remain free, even when patients opt to have treatment privately; the same applies for radiotherapy treatment [2].

Furthermore the financial crisis has resulted in reduced ability of patients to pay for private health care (e.g., due to some patients becoming unemployed or patients suffering from large pay cuts), and hence shifting more activity to the public sector, resulting in a further unused capacity in the private sector. At the same time the Public Health care expenditure has been reduced from a peak of 605 million euros in 2011 [30] to 530 million euros, and private sector expenditure from 704 to 580 million euros [30]. This is in the background of a country already dedicating less proportionally of its GDP to health care compared to other European Countries even prior to the financial crisis; in 2011 Cyprus spent 7.3 % of its GDP towards health care, which is lower than the 8.9 % average of the European Union [30].

As a result of the austerity budget of the MoH for both 2014 and 2015, significant cutbacks were made to Cancer Services expenditure across the board, beyond the new charges introduced for cancer patients. For the BOCOC, funding from the government went down from 15.8 million in 2012 prior to the crisis to 14.7 million in 2015, despite a significant increase of activity levels over this period. Equally financial support of the BOCOC suffered as a result of the financial difficulties of the Bank of Cyprus (BOC), resulting in a cap of donation from the BOC to 2.5 million, whilst the commitment for future equipment replacement is going to be reviewed on a year-by-year basis. In terms of public sector Oncology services, previous plans for two new radiotherapy centres are currently under review.