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EUROCHIP
Health Indicators for Monitoring Cancer in Europe
Health Monitoring Program (HMP) EUROPEAN
COMMISSION HEALTH CONSUMER PROTECTION
DIRECTORATE-GENERAL
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EUROCHIP INTRODUCTION
AIM To produce a list of health indicators which
describe cancer in Europe, to help the
development of the future European Health
Information System STEP 1 (Jan 2002 Jul 2002)
To discuss a preliminary list at national level,
in all members of the European Union. The result
was a list of more than 100 indicators subdivided
by priority level STEP 2 (Sep 2002 Dec 2002)
To discuss the indicators (of the list produced
at STEP 1) by different domain (prevention,
epidemiology and cancer registration, screening,
treatment and clinical aspects, and macro
social-economic variables). To discuss
methodological problems for the indicators at
high priority. STEP 3 (Jan 2003 May 2003)
Definition of the final list of indicators
subdivided by domain and by priority level.
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EUROCHIP
Comprehensive range of health indicators for
cancer
OCCURENCE
RISK FACTORS
LIST OF CANCER INDICATORS
PRE-CLINICAL ACTIVITY/ SCREENING
SURVIVAL
CAMON EUROCARE/EUROPREVAL
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
CANCER CARE/ PREVALENCE
CANCER RECURRENCE AND MORTALITY
CLINICAL FOLLOW-UP
Standardised methods for collecting, checking and
validating the data will be proposed for each
indicator
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STEPS
130 CANCER SPECIALISTS ARE INVOLVED IN
EUROCHIP 23 INTERNATIONAL MEETINGS
HELD ALL COUNTRIES OF THE EUROPEAN UNION ARE
PARTICIPATING IN THE PROJECT

• This step
• Final meeting at which the final selection of
  indicators will be drawn up

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RESULTS

• For each indicator we compile a FORM subdivided
  in three sections
• DESIRED INDICATOR all indicator characteristics
  we wish to have
• METHODOLOGY operational definition, possible
  sources and methodological issues
• AVAILABILITY in different countries

LIST OF INDICATORS
PRELIMINARY LIST OF 158 INDICATORS
EUROCHIP MEETINGS
60 INDICATORS SUBDIVIDED BY DOMAIN
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EUROCHIP FINAL RESULTS(AT THE END OF STEP 3)

• For each indicator EUROCHIP will produce
• A DESCRIPTIVE FORM including
• Desired indicators characteristics (definition,
  use, caveat )
• Operational definition and indications on sources
• Indications on availability in all EU member
  countries
• A METHODOLOGICAL FORM including
• Methodological aspects (standardisation,
  validity, variability)
• Bibliography on the indicator
• Suggestions to the European Commission

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FUTURE

• EUROCHIP 2
• National EUROCHIP groups
• Publications

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PUBLICATIONS

• European Journal of Public Health special
  number with the abstracts of the EUPHA meeting
  (Dresden, Nov 2002)
• Cultural spanish review Las Claras an
  article on the EUROCHIP Murcia meeting will be
  published
• European Journal of Public Health an article on
  EUROCHIP is under review

NATIONAL OR INTERNATIONAL MEETINGS

• Abstracts of various presentations or posters are
  under review for
• NAACCR annual meeting Honolulu (Jun 03)
• AIRT (Italian association CR) meeting Biella
  (Apr 03)
• Reunion du groupe pour l'epidemiologie et
  l'enregistrement du cancer dans le pays de langue
  latine Cuba (May 03)
• Sociedad Española de Epidemiología meeting
  Toledo (Oct 03)

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PLAN OF THE PUBLICATIONS

• The Steering Committee decided this plan of
  publications
• 1 article with EUROCHIP introduction EUROPEAN
  JOURNAL OF CANCER or EUROPEAN JOURNAL OF PUBLIC
  HEALTH
• 1 article on methodological aspects ?
• 1 article on treatment aspects EUROPEAN JOURNAL
  OF CANCER
• 1 article on prevention EUROPEAN JOURNAL OF
  CANCER ON PREVENTION
• 1 article on screening EUROPEAN JOURNAL OF
  CANCER ON PREVENTION
• 1 article on cancer registration and
  epidemiology EUROPEAN JOURNAL OF CANCER
• Preparation before summer In press
  October-November

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AIMS OF THE MEETING

• Approval of the entire list with relevant
  material
• Give a priority to the indicators to find 15-20
  most important indicators
• A look of the future

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EUROCHIP PROJECT LIST OF INDICATORS
GOAL PRIORITIES
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AXES OF CLASSIFICATION

• The natural history of cancer
• Prevention
• Screening
• Diagnosis
• Treatment
• End results
• ECHI classification
• Demographic and social-economic factors
• Health status
• Determinants of health
• Health system
• Tumour sites

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CANCER SITES (1)

• All cancers combined without non melanoma skin
  cancers for cancer burden and cancer trends. For
  total cost of cancer care. For Incidence and
  mortality
• Major cancers (in terms of incidence or
  prevalence)
• Lung for prevention, tobacco smoking (very
  limited for asbestos). For mortality (in
  countries without data). For preventable
  estimation of deaths
• Breast for monitoring screening programmes
  (mortality and incidence) and to evaluate the
  care (tamoxifen)
• Colorectal to evaluate the care, evaluation of
  early diagnosis (and screening programmes ). For
  delay of diagnosis
• Prostate for future trends and future resources

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CANCER SITES (2)

• Other major cancers
• Stomach for monitoring the decreasing trends
  (ethnic differences)
• Head and neck-larynx, oropharynx (specifying
  ICD-9 code) for prevention and care. Treatment
  for organ preservation. Melanoma for prevention
  (early diagnosis-stage migration)
• Bladder for mortality
• Other cancers
• Kaposi for sentinel
• Mesothelioma for sentinel
• Testis for rare cancer
• Lymphomas (H for health services and NH for
  trends) and Leukaemia (for treatment)
• All (or just Leukaemia?) childhood (0-14) cancers
  (for survival) rare cancer
• Cervix (for screening) We need information on
  incidence and mortality (note corpus uteri vs
  cervix misclassification)

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BACKGROUND OF THE LIST

• The final list is the result of various
• discussions on the priorities of each indicator.
• These priorities considered together
• added value of the indicator,
• problems on the collection of the data,
• problems on the comparability among European
  countries, and
• costs of the collection

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INDICATORS UNRESOLVED PROBLEMS (1)

• Awareness of risk associated to exposure to UV
  radiations which question for the survey?
• PM10 emissions cut-off
• Screening coverage indicators only on organized
  screening or also on opportunistic screening?
  Which source?

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PAGES 63-68
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INDICATORS UNRESOLVED PROBLEMS (2)

• Number of units with at least 2 Linear
  Accelerators or with a single Lin Acc.
• Patients treated by surgery, chemotherapy which
  is the utility of this indicator after the
  collection of the indicator deviance from best
  oncology practice?
• Palliative care which indicator?

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PAGES 113-116
PAGE 117
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PREVENTION 14 (4) Lifestyle 7 (0) Environment
Occupational risk 6 (4) Medicaments 1
(0) EPIDEMIOLOGY AND CANCER REGISTRATION 10
(5) Cancer registration coverage 1
(1) Epidemiological measure 7 (3) Cancer
registration quality 2 (1) SCREENING 13
(13) Screening coverage 3 (3) National
evaluation of org. scr. process indicators 10
(10) TREATMENT AND CLINICAL ASPECTS 10
(10) Health system delay 1 (1) Resources 3
(3) Treatment 5 (5) Palliative care 1
(1) SOCIAL AND MACRO-ECONOMIC VARIABLES 18
(8) Social indicators 3 (0) Macro economic
indicators 13 (8) Demographic indicators 2 (0)
L I S T
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PR 7 hp (2) 4 mp (2) EP 6 hp (2) SC 4 hp
(4) 7 mp (7) TR 5 hp (5) 3 mp (3) MV 5 hp
(2) 11 mp (2) 27 hp (15) 25 mp (14)
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LEGENDA OF NEXT SLIDES

• In red indicators proposed by EUROCHIP
• In black indicators proposed by other projects
  or networks
• In CAPITAL indicators at high priority
• In small indicators at medium priority

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INDICATORS ALREADY AVAILABLE - LOW COSTS or NO
NEW COSTS

• EXPOSURE TO ASBESTOS MESOTHELIOMA INCIDENCE
  
• AND MORTALITY TRENDS
• CANCER INCIDENCE RATE AND TREND
• CANCER SURVIVAL RATE AND TREND
• CANCER PREVALENCE PROPORTION AND TREND
• CANCER MORTALITY RATE AND TREND
• PERSON-YEARS LIFE LOST DUE TO CANCER
• POPULATION COVERED BY CRs IN EUROCIM DATABASE
• Percentage of cases confirmed microscopically
• Education level attained
• Average income and Ginis index
• GROSS DOMESTIC PRODUCT
• TOTAL SOCIAL EXPENDITURE
• TOTAL NATIONAL EXPENDITURE ON HEALTH
• TOTAL PUBLIC EXPENDITURE ON HEALTH
• Age distribution in 2010-20-30
• Life table quantities

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SOURCES ALREADY AVAILABLE - LOW COSTS or NO NEW
COSTS

• ANTI-TOBACCO REGULATIONS
• NATIONAL EVALUATION IN HMP OF THE ORGANIZED
  SCREENING PROCESS INDICATORS
• SCREENING VOLUME
• SCREENING RECALL RATE
• SCREENING DETECTION RATE
• SCREENING LOCALIZED CANCERS
• SCREENING BENIGN/MALIGNANT BIOPSY RATIO
• SCREENING INTERVAL CANCERS
• SCREENING SENSITIVITY
• SCREENING SPECIFICITY

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SOURCE UPDATE OF DATABASES - MEDIUM COSTS

• PREVALENCE OF OCCUPATIONAL EXPOSURE TO
  CARCINOGENS
• PM10 EMISSIONS

SOURCE HEALTH SURVEYS - MEDIUM COSTS

• Consumption of fruit and vegetables
• Consumption of alcohol
• Body Mass Index distribution in the population
• Physical activity
• PREVAL. OF CURRENT TOBACCO SMOKERS AMONG
• ADULTS
• PREVALENCE OF TOBACCO SMOKERS AMONG 10-14
• PREVALENCE OF EX-SMOKERS
• Prevalence population exposed to environmental
  tobacco smoke (ETS)
• Awareness of risk associated to exposure to
  Ultra-Violet radiations
• Breast cancer screening coverage
• Cervical cancer screening coverage
• Colo-rectal cancer screening coverage

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SOURCE OTHER SURVEYS - MEDIUM COSTS

• OF RADIATION EQUIPMENTS ON POPULATION
• OF UNITS WITH AT LEAST 2 LINACS
• OF CT (COMPUTED AXIAL TOMOGRAPHY) ON POP.
• PUBLIC EXPENDITURE FOR CANCER DRUGS
• Public expenditure for cancer prevention on
  anti-tobacco activity
• Public expenditure for organized mass screening
  programmes
• Private/Non profit expenditure on cancer
  screening
• Public expenditure for cancer research
• Private non profit expenditure for cancer
  research
• Public expenditure for population-based Cancer
  Registries
• Private/Non profit expenditure for cancer
  registration
• Prevalence of use of hormonal replacement
  treatment drugs
• Palliative care indicator

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SOURCE CANCER REGISTRIES - HIGH COSTS

• STAGE AT DIAGNOSIS CASES RECORDED IN CRS AND
• MEDICAL RECORDS
• Completeness of cancer registration
• DELAY OF CANCER TREATMENT
• DEVIANCE FROM BEST ONCOLOGY PRACTICE
• Patients treated by
• - Surgery
• - Chemotherapy
• - Radiotherapy
• - Endocrine therapy

SOURCE OTHER - HIGH COSTS

• Indoor radon exposure

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INTRODUCTION
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AXES OF CLASSIFICATION

• The natural history of cancer
• Prevention
• Screening
• Diagnosis
• Treatment
• End results
• ECHI classification
• Demographic and social-economic factors
• Health status
• Determinants of health
• Health system
• Tumour sites

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CANCER SITES (1)

• All cancers combined without non melanoma skin
  cancers for cancer burden and cancer trends. For
  total cost of cancer care. For Incidence and
  mortality
• Major cancers (in terms of incidence or
  prevalence)
• Lung for prevention, tobacco smoking (very
  limited for asbestos). For mortality (in
  countries without data). For preventable
  estimation of deaths
• Breast for monitoring screening programmes
  (mortality and incidence) and to evaluate the
  care (tamoxifen)
• Colorectal to evaluate the care, evaluation of
  early diagnosis (and screening programmes ). For
  delay of diagnosis
• Prostate for future trends and future resources

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CANCER SITES (2)

• Other major cancers
• Stomach for monitoring the decreasing trends
  (ethnic differences)
• Head and neck-larynx, oropharynx (specifying
  ICD-9 code) for prevention and care. Treatment
  for organ preservation. For quality of life
• Melanoma for prevention (early diagnosis-stage
  migration)
• Other cancers
• Kaposi for sentinel
• Mesothelioma for sentinel
• Testis for rare cancer
• Lymphomas (H for health services and NH for
  trends) and Leukaemia (for treatment)
• All (or just Leukaemia?) childhood (0-14) cancers
  (for survival) rare cancer
• Cervix (for screening) We need information on
  incidence and mortality (note corpus uteri vs
  cervix misclassification)

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INDICATORS (at high priority)
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EXPOSURE TO ASBESTOS MESOTHELIOMA INCIDENCE AND
MORTALITY TRENDS
Incidence/Mortality variations for Pleureal
cancer and/or Perithoneal cancer and/or
Mesothelioma by period and by administrative unit
DEFINITION
The recent trends of mesothelioma or pleural and
perithoneal cancers mortality and incidence (last
3-5 years) can be real proxies of the exposure to
asbestos in the past. They indicate either
increasing, decreasing or even stable rates, thus
indicating a different phase of the asbestos
epidemic.
INDICATORS ALREADY AVAILABLE
NO NEW COSTS
HIGH PRIORITY
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PERSON-YEARS OF LIFE LOST DUE TO CANCER
Years lost due to cancer using general life
expectancy as reference
DEFINITION
FORMULA
where aage, lage limit, datnumber of deaths at
age a, patnumber of persons aged a in country i
at time t, Panumber of persons aged a in the
reference population, Pntotal number of persons
aged 0 to l-1 in the reference population
SOURCES ALREADY AVAILABLE
LOW COSTS
HIGH PRIORITY
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POPULATION COVERED BY CANCER REGISTRIES PRESENT
IN EUROCIM DATABASE
Proportion of the national population that is
covered by general population-based Cancer
Registries present in the EUROCIM database in a
given period (year)
DEFINITION
By registration span. For a given calendar year,
the indicator shows the percentage of cancer
registration coverage of 5, 10 and 20 years at
least
CLASSIFICATION
INDICATORS ALREADY AVAILABLE
NO NEW COSTS
HIGH PRIORITY
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NATIONAL EVALUATION IN HMP OF THE ORGANIZED
SCREENING PROCESS INDICATORS
The screening group underlined the importance
to realise in HMP a national evaluations of the
process indicators of the organised screening
programmes activity. The group individuated the
information necessary for this national
evaluation Breast and colo-rectal
cancer Extension gt Availability of the
programmes in the pop. and coverage
Acceptance gt Participation Specificity gt Recall
ed, benign operations (open surgical
procedures) Sensitivity gt Detected by
stage Cervical cancer Extension gt Availability
of the programmes in the pop. and coverage
Acceptance gt Participation Specificity gt Recall
ed (anything no negative) Sensitivity gt Detected
by CIN (histology) and invasive by stage
SOURCES ALREADY AVAILABLE
LOW COSTS
HIGH PRIORITY
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ANTI-TOBACCO REGULATIONS

• The indicator refers to the description of the
  anti-tobacco regulation.
• It is a multiple-indicator indicating presence or
  absence (Y/N) of a set of specific laws on
  anti-tobacco regulation. These laws should refer
  to
• restrictions in public places
• prohibition in hospitals
• prohibition at school (or universities)
• prohibition in public transport vehicles
• on-pack warnings
• indications on nicotine on pack
• limits on tar content
• employeees protection law (ETS)
• prohibition of Tv and radio advertising
• flight smoke prohibition in national airline
• sales to children/teenagers
• tobacco smoke labeled as a carcinogen

HIGH PRIORITY
SOURCES ALREADY AVAILABLE
LOW COSTS
SOURCE Corrao MA et al. Tobacco Control Country
Profiles. American Cancer Society, Atlanta, GA
(2000)
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PREVALENCE OF OCCUPATIONAL EXPOSURE TO CARCINOGENS
Current prevalence of occupational exposure to a
given carcinogen (recognized by the
International Agency for Research on Cancer in
the classifications 1, 2A and 2B)
DEFINITION
EUROCHIP suggest to update and expand the present
CAREX database. This database, subsidized by the
Europe Against Cancer Programme, estimated the
occupational exposure in all European countries
by agent and by industries for the period
1990-93. Updating the already available database
with the same methodology we could also study if
in the country the occupational exposure to
carcinogens is changed in this 10 years
UPDATE OF AVAILABLE DATABANKS
MEDIUM COSTS
HIGH PRIORITY
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PM10 (PARTICULATE MATTER lt 10µ3) EMISSIONS
Percentage of population living in areas with a
PM10 daily average concentration above ?
microgrammes per air cubic metre
DEFINITION
MEDIUM COSTS
Percentage of population living in urban areas
with a PM10 daily average above 50 microgrammes
per air cubic metre is an indicator proposed in
Europe by the group Environmental health
indicators for the WHO Europe. This group
already provided a methodological definition of
the indicator and also considers it as a
realistic goal in the next future.
This indicator is the same proposed by EUROCHIP
(we had not proposed any limit value, as yet) so
we recommends the EC to include in the European
Database also this indicator of the WHO group.
The only doubt is the value of 50 microgrammes
per air cubic metre because the EU directive
indicates a lower value
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INDICATORS ON TOBACCO

• Prevalence of current tobacco smokers among
  adults
• Prevalence of tobacco smokers among 10-14
• Prevalence of ex-smokers
• Prevalence of exposure to environmental tobacco
  
• smoke (ETS)

The project EHRM (European Health Risk
Monitoring) proposed the same indicators of
EUROCHIP.
HEALTH SURVEY
MEDIUM COSTS
HIGH PRIORITY
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INDICATORS ON RESOURCES
Number of linear accelerators per 1 000 000
population
RADIATION EQ.
Number of CT (Computed Axial Tomography or
computed tomography scanners) equipments per 1
000 000 population
CT
Number of units with at least 2 Linear
Accelerator radiation equipments per 1 000 000
population OR Number of units with a single
Linear Accelerator
OTHER
Survey on health structures and services. The
resource have to be working on 31st December of
the year prior to the survey
SOURCE
MEDIUM COSTS
OTHER SURVEYS
HIGH PRIORITY
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STAGE AT DIAGNOSIS CLARIFICATIONS
We need to have this information
CANCER REGISTRIES
HIGH COSTS
HIGH PRIORITY
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STAGE AT DIAGNOSIS PERCENT OF CASES RECORDED IN
CANCER REGISTRIES
Proportion of cases classified with the TNM value
or, in absence, with condensed-TNM
DEFINITION
The expected value of this percentage is site
dependent. For some sites (like lung) the
expected value of the indicator is lower than
100, but comparisons among countries are still
informative.
CONTEXT
The sources are the Cancer Registries and exactly
their routinary activity of registration
SOURCE
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STAGE AT DIAGNOSIS PERCENT OF CASES RECORDED IN
MEDICAL RECORDS
Percentage of cancer cases registered by the
clinician with the information of the presence or
absence of a detection tests for metastasis
DEFINITION
- Cervix chest x-ray and pelvic imagine - Colon
and rectum liver ultrasound or CT and chest
x-ray - Prostate bone-scan - Lung CT thorax -
Breast different per stage - T1-T2 chest
x-ray - T3-T4 or N bone-scan and liver
ultrasound
DETECTION TESTS
The sources are the Cancer Registries performing
specific studies for major cancer sites
SOURCE
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DELAY OF CANCER TREATMENT CONTEXT
Phases of the disease history Symptoms there
is not an event and for this it is not strictly
defined on time First medical attendance date
on which patient reports his symptoms to the
Health System (general practitioner, hospital
...) Diagnosis date defined specifically site
per site First treatment date of the beginning
of primary treatment. The date of first symptoms
is not intrinsically defined as an event and for
this reason we suggest to use the date of the
first diagnosis (or first medical attendance for
some sites) as a reference. The treatment group
suggests specifically definitions for the dates
of first diagnosis (or first medical attendance)
and of first treatment for 5 cancer sites
breast, colon, rectum, lung and prostate. The
Methodological Group suggests to study only
breast, colon and rectum for the high percentage
of patients non-treated. To define these
indicators, the Cancer Registries have to collect
the dates of first treatment (and exactly on
surgery, chemotherapy, radiotherapy or endocrine
therapy)
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DELAY OF CANCER TREATMENT DEFINITION OF THE DATES
HIGH COSTS
CANCER REGISTRIES
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DELAY OF CANCER TREATMENT COMMENTS
Isabel Izarzugaza (Basque Country Cancer
Registry) The data for the delay of cancer
treatment indicator could be collected
periodically for breast and colorectum. In a
different period for prostate, in a different
period for some other tumour. For example during
1 year every 3 years breast and colorectum, the
following year (everey 3 years) for prostate and
so on. Risto Sankila (Cancer Registry of
Finland Why do we collect data, e.g. on delay of
care, when in some parts of the expanding EU
there are no resources for proper
diagnostics!Who will utilise the information on
'Interval between first diagnosis and first
treatment' on the EU level, if the data are only
collected from a (biased?) sample of cancer
clinics? (To be continued)
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DELAY OF CANCER TREATMENT COMMENTS
Torgil Moller (Swedish Cancer registry) I think
this is a very difficult item if you wish to
study the time from symptom to diagnosis and
diagnosis to treatment. The date of start of
symptom is often very vague and undefined, maybe
preceeded by irrelevant symptoms and thus a
matter of great subjectivity. I would like to
suggest date of first contact with health care
system leading to the diagnosis in question as
the starting point. This is of course also a
difficult item to collect, and necessitates maybe
visits to primary health care centres and GPs,
but in any case it is a date that could be
defined. The next problem relates to date of
diagnosis. If we are studying delay in the
system, the date of histological confirmation
based on surgical specimen would in many cases
result in a negative delay between date of
diagnosis and date of start of treatment. Thus,
it is important to accept for example a positive
mammography plus cytology as the date of
diagnosis, or clinical investigation where no
histological confirmation can be obtained, for
example melanoma of the eye or tumour of the
brain stem. If this problem can be solved, then
this indicator might be of value. However, it
could never be based on a routine data collection
but must be collected now and then within well
defined projects.
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DEVIANCE FROM BEST ONCOLOGY PRACTICE CONTEXT
The indicator is aimed to reflect the deviance to
best practice in oncology. It implies the
existence of specific professional guidelines and
express something related to the attitude to
comply with guidelines rather best practice. To
give an indication on the patients treated
according to the guidelines, we need to collapse
the guidelines themselves into a few simple
items. As guidelines usually refer to cases that
can be potentially cured, the indicator should
refer to patients potentially eligible for
treatment according to guidelines. An
examination of the deviation from guidelines is
usually more robust than a look at their
adherence. The medical attitude in following
guidelines may vary considerably and thus, is
very difficult to classify. Defining the
non-adherence is easier and more robust.
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Example
As an example, Sant (2001) showed that in
Southern Italy a very low proportion of breast
cancer patients T1N0M0 were treated with
conservative surgery while many received Hastled
mastectomy. This a clear deviation to guidelines,
although motivated by lack of radiotherapy
centres in the area. Source Sant M, and the
EUROCARE Working Group Differences in stage and
therapy for breast cancer across Europe.
International Journal of Cancer 93 894-901
(2001)
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DEVIANCE FROM BEST ONCOLOGY PRACTICE CASES
BREAST - Proportion of patients receiving
post-operative breast radiotherapy after breast
conserving surgery (by age) - Proportion of
patients with pathological or clinical tumour
site 3cm or less receiving conserving surgery (by
age) COLON - Proportion of patients with Dukes C
receiving adjuvant chemotherapy RECTUM -
Proportion of patients receiving pre-operative
radiotherapy PROSTATE - Proportion of patients
receiving radical prostatectomy (by age) - Prop.
of patients receiving radical radiotherapy by
external beam or brachytherapy LUNG - Proportion
of patients with non small cell undergoing
radical surgery - Proportion of patients
undergoing staging with thoracic CT scanning
CERVIX - Prop. of patients with FIGO-stage
III/IV in cervix cancer receiving
chemoradiotherapy (by age) - Prop. of patients
undergoing WERTHEIM-MEIGS hystorectomy by
FIGO-stage (including insitu) (by age)
CANCER REGISTRIES
HIGH COSTS
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DEVIANCE FROM BEST ONCOLOGY PRACTICE COMMENTS
Isabel Garau (Mallorca Cancer Registry) Guidelines
on diagnostic procedures may vary from country
to country and even for the areas covered by the
cancer registries, but, when defined, (and I
think that is possible to define guidelines on
this point) I think that cancer registries could
be able to collect these information. But define
guidelines for treatment into a simple way could
be very difficult (specially for the most
interesting tumours) and, even if defined, I'm
not sure that cancer registries would be able to
collect this information. I propose a reflection
and, if necessary, a pilot study on this
indicator. Torgil Moller (Swedish Cancer
registry) Indicator Deviance from best oncology
practice also needs a lot of definition and
could maybe only be applied in certain situations
where there is a common agreement on the
treatment method, such as breast conserving
surgery, preoperative radiotherapy in rectal
carcinoma, etc. This indicator must also be
collected only within well defined projects, but
could be of great importance
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INDICATORS (at medium priority)
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CONSUMPTION OF FRUIT VEGETABLES
MEDIUM COSTS
Distribution of the population by daily portion
of all fruits and vegetables (excluding potato)
DEFINITION
EFCOSUM (European Food Consumption Survey Method)
underlined DAFNE is the only database
providing comparable data (household) EPIC
develops methods to collect data focused on
cancer and adults Common guidelines are
necessary in order to have comparable data Data
can be made comparable at the raw edible
ingredient level It is really important have
comparable data on vegetables (potatoes
excluded), fruits (fruit juices excluded), bread,
fish (stellfish included), some nutrients
(saturated fatty acids, total fat, ethanol) and
some biomarkers (folate, vitamin D, iron, iodine,
sodium) EUROCHIP is aware of the difficulties to
have comparable data on dietary habits but also
of the real importance to have this information
as the consumption of fruit vegetables is a
major dietary protective factor for cancer. For
this reason EUROCHIP recommends the carrying on
of projects like EFCOSUM, DAFNE and EPIC.
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CONSUMPTION OF ALCOHOL
MEDIUM COSTS
DEFINITION
Pure alcohol daily consumption
ECAS (European Comparative Alcohol Study)
underlined Total alcohol consumption per
capita by beverage categories is an important
indicator for following developments in the EU
public health EU should prepare an
authoritative report on tot. alcohol cons.
according to beverage categories and off- and
on-premises sales EU should also prepare a
report on how basic figures for alcohol cons. are
and have been collected in different studies and
how units used for estimating individual
consumption have been converted into litres
The EU should carry out such surveys on a regular
basis in order to monitor developments in
drinking habits EUROCHIP agreed with the ECAS
recommendations to the EU and underlines the
importance to have a common European guideline in
order to have comparable data
ECAS (European Comparative Alcohol Study)
underlined Total alcohol consumption per
capita by beverage categories is an important
indicator for following developments in the EU
public health EU should prepare an
authoritative report on tot. alcohol cons.
according to beverage categories and off- and
on-premises sales EU should also prepare a
report on how basic figures for alcohol cons. are
and have been collected in different studies and
how units used for estimating individual
consumption have been converted into litres
The EU should carry out such surveys on a regular
basis in order to monitor developments in
drinking habits EUROCHIP agreed with the ECAS
recommendations to the EU and underlines the
importance to have a common European guideline in
order to have comparable data
ECAS (European Comparative Alcohol Study)
underlined Total alcohol consumption per
capita by beverage categories is an important
indicator for following developments in the EU
public health EU should prepare an
authoritative report on tot. alcohol cons.
according to beverage categories and off- and
on-premises sales EU should also prepare a
report on how basic figures for alcohol cons. are
and have been collected in different studies and
how units used for estimating individual
consumption have been converted into litres
The EU should carry out such surveys on a regular
basis in order to monitor developments in
drinking habits EUROCHIP agreed with the ECAS
recommendations to the EU and underlines the
importance to have a common European guideline in
order to have comparable data
57
BODY MASS INDEX DISTRIBUTION IN THE POPULATION
Percentage of obese and overweight population by
BMI (Body Mass Index)
DEFINITION
BMI values 25-30 Kg/m2 Overweight 30
Kg/m2 Obesity
The project EHRM (European Health Risk
Monitoring) underlined the importance to have
information on BMI in the EU. It proposes the
same indicator proposed by EUROCHIP.
HEALTH SURVEY
MEDIUM COSTS
58
PHYSICAL ACTIVITY
MEDIUM COSTS
Proportion of people carrying out physical
activity (moderate and strenuous activities) by
number of hours per working days or holidays
DEFINITION
EUPASS (European Physical Activity Surveillance
System) recommended an European survey on
physical activity (IPAQ) including various
questions. The EUROCHIP indicator refers to the
question A2 in the IPAQ
A2. How much time on average do you spend per day
(24 hours) on (Round up time to full or half
hours Like 0,5 Hrs. This concerns only physical
activities or efforts. Please try to distribute
all 24 hours over the 5 categories) Mon-Fri S
at-Sun Sleeping, resting __ __, __h __ __,
__h Sitting __ __, __h __ __, __h (like
at the office, in the car, watching television,
eating, reading) Light activities __ __,
__h __ __, __h (like cooking, walking at low
pace, shopping, tiding up the room, body care,
selling) Moderate activities __ __, __h __
__, __h (like jogging, renovating, cleaning,
construction work) Strenuous activities __
__, __h __ __, __h (like carrying heavy
weights, strenuous gardening, chopping wood,
competitive sport, ball games) Total
24,0h 24,0h
59
AWARENESS OF RISK ASSOCIATED TO EXPOSURE TO UV
RADIATIONS
Proportion of persons reporting to be aware (or
not aware) with the UV radiation and reporting to
behave (or not to behave) consistently
DEFINITION
MEDIUM COSTS
Skin cancer incidences are increasing. Exposure
of UV radiations is the major cause of skin
cancers and it is a behavioural trait. Awareness
is the only control measure
RATIONALE
SOURCE
Health survey
From EHRM (European Health Risk Monitoring)
project leader Concerning the indicator of
ultraviolet raditions, are you proposing a
questionnaire item for collecting the
information? I do not know if there are validated
questions which could be used.
60
PREVALENCE OF USE OF HORMONAL REPLACEMENT
TREATMENT DRUGS
Hormonal Replacement Treatment drug use in the
female population from 50 to 69
DEFINITION
The indicator refers to the number of
prescriptions HRT in women (indicator proposed by
the pharmaceutical HMP project)
MEDIUM COSTS
61
SCREENING COVERAGE INDICATORS
It considers the effects of both organized and
opportunistic screenings
CONTEXT
Percentage of women aged between 40-49, 50-69 and
70-74 examined by mammography in the recommended
interval
BREAST
Percentage of women aged 20-29, 30-59 and 60
examined by citology in the last 3-5 years
CERVIX
Percentage of persons aged 50-74 who have had a
fecal occult-blood test in the last 2 years
COLO-RECTAL
Organized screening programme databases for
countries with national programmes. In this case
we need the information on the frequency of
mammography examinations for females who did not
comply to participate to the screening. For the
other countries data should be collected by
survey and we need also information from regional
programmes
SOURCE
MEDIUM COSTS
62
INDICATORS ON PALLIATIVE CARE
Use of morphine units per cancer patients
INDICATOR 1
Beds in palliative units in specialist level and
in primary care level
INDICATOR 2
Number of patients who have got palliative
radiotherapy or fractions of radiotherapy as
palliative purpose
INDICATOR 3
MEDIUM COSTS
63
INDICATORS ON PUBLIC/PRIVATE EXPENDIT. FOR CANCER
Public expenditure for cancer prevention on
anti-tobacco activity (campaigns, initiatives,
facilities and so on against tobacco)
PREVENTION
Public and Private/Non profit expenditure devoted
to support population-based cancer registration
(SOURCE question to CR)
CR
Public and Private/Non profit expendit. for
cancer organized mass screening programs by site
(SOURCE question to EBCN)
SCREENING
MEDIUM COSTS
Public expenditure for cancer clinical trials not
supported by pharmaceutical companies,
fundamental research and contributions from
International Organisations
RESEARCH
Private non profit expenditure for cancer
research regarding charity organizations
(specialized in cancer) reviewing reasearch
SOURCE survey
64
COMPLETENESS OF CANCER REGISTRATION
Completeness measure proposed in Bullard J,
Coleman MP, Robinson D, LUTZ JM, Bell J, Peto J.
Completeness of cancer registration a new method
for routine use. British Journal of cancer (2000)
82(5), 1111-1116
DEFINITION
FORMULA
where s(ti) probability that a cancer patient
is still surviving at time ti after diagnosis,
m(ti) probability that the death certificate of
a patient who dies in the time
interval (ti, ti1 ) after diagnosis includes a
mention of cancer u(ti) probability that a
patient surviving until time ti) after diagnosis
is still unregistered
MEDIUM COSTS
65
PATIENTS TREATED BY SURGERY, CHEMOTHERAPY ...
Percentage of patients treated with surgery,
chemotherapy and radiotherapy.
CONTEXT
The sources should be the Cancer Registries. We
suggest specific studies on sample of cases in
order to collect information on therapy and
stage, such as the EUROCARE High Resolution
Studies
SOURCE
It is not clear what the indicator would like to
present. It should be interpreted generally as
frequency of a specific treatment. It is not
clear the rationale and the added value of the
indicator if we have a good indicator on
deviance from best oncology practice this
indicator should became redondant
66
HIGH COSTS
INDOOR RADON EXPOSURE
Percentage of people living in houses with radon
gas concentration above 200Bq/m3
DEFINITION
The source will be national ad hoc surveys. In
the 90s Each European country organized a survey
to know the radon levels in dwellings in their
territory. One of the results was the percentage
of dwellings with a radon level over
200Bq/m3 Bibliography Bochicchio F et al. Radon
in indoor air. Luxembourg, Office for Official
Publications of the European Communities, 1995
(European Collaborative Action Indoor air
quality and its impact on man, No. 15)