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CANCER MONITORING IN ROMANIA
Report on available indicators and proposed actions in the frame of EUROCHIP II
The importance of the cancer control programs is stressed by two international leaders in
the field: IARC- World Health Organization (WHO) and Cancer Prevention ControlCenter for Disease Control (CDC). In 1995 WHO published the first document on
“National Cancer Control Programs” and CDC has developed a model framework for
Comprehensive Cancer Control. Cancer monitoring is nowadays a fundamental
instrument of every national cancer control program. Its importance derives from the
necessity to identify several evidence-based strategies and choose those that are feasible
to implement, acceptable and relevant to the society, when planning a national cancer
program.
In Romania, the following monitoring cancer programs are run:

2. The National Program for Public Health for Prevention and Control of NCD;
2.2 Prevention and Control in Oncology

EU Phare Project RO-2002/000-586.04.11.03 entitled “Improvement of NCD
monitoring and evaluation capacity in the context pf health care sector reform in
Romania”(2002-2004)

European Cancer Health Indicator Project –EUROCHIP II, a EU project within
the framework of the European Health Monitoring Programs (HMP)
The evaluation of the existing cancer monitoring system begins with data sources
description. The principal data sources are: the Romanian Cancer Registry, Romanian
health surveys (polls), the Romanian Ministry of Health Report/2004, EU Phare RO2002/000-586.04.11.03 interim report and EUROCHIP questionnaire.
From these data sources we have verified the availability of cancer indicators in
Romania, in relation with EUROCHIP indicator list.
1 Pra
2Epa
3Sca
4 Tra
5Mva
Prevention
Epidemiology&Cancer
Screening
Treatment&Clinical Aspects
Macro-social
Registration
Lyfestyle
01 Consumption of fruit and
vegetables*
02 Consumption of alcohol*
03
Body
Mass
Index
distribution in the population*
04 Physical activity*
05 Tabacco survey*: prevalence
of
a)tabacco smokers among adults
b)tabacco smokers among 10-14
years olds
c)ex-smokers
Environment&Occupational
Risk
d)exposure to environmental
tabacco smoke (ETS)
06 Exposure to sun radiation
07 PM 10 (particulate matter=10
um3) emissions
08 Prevalence of occupational
exposure to carcinogens
10
Exposure
to
asbestos:mesothelioma incidence
and mortality trends
Medicaments
11. Prevalence of use of
hormonal replacement drugs*
1 Population covered by
high quality Cancer
Registries.
2 Cancer incidence rates,
trends and projections*.
3
Cancer
relative
survival rates, trends
and projections*.
4 Cancer prevalence
proportions, trends and
projections*.
5 Cancer mortality
rates, trends, projections
and person-years of life
lost due to cancer*
6 Stage of diagnosis:
percentage of
a) cases with early
diagnosis
b) cases with a
metastatic test
and
Economic
Variables
Screening examinations
1 Precentage of women that
have
undergone
a
mammography (brest cancer)
2 Percentage of women that
have undergone a cervical
cytology
examination
(cervical cancer)
3 Percentage of persons that
have undergone a colorectal
cancer screening test.
National evaluation in HMP of
organized
mass
screening
process indicators
4a
Organized
screening
coverage
4b Screening recall rate
4c Screening detection rate
4d Screening localized cancers
4e
Screening
positive
predictive value
4f Screening benign/malignant
biopsy ratio
4g Screening interval cancers
4h Screening specificity
Health system delay
1 Delay of cancer tretment (pilot
studies)
Resources
2 Percentage of radiation system
in the population
3 Percentage of diagnostic
Coomputed Axial Tomographies
(CTs) in the population
4 Percentage of Positron Emission
Tomographies
(PETs)
on
population(for future)
5 Percentage of magnetic resonances
on population (for future)
Treatment
6 Compliance with best oncology
practice
Palliative care
7 Use of morphine in cancer patients
8 Percentage of patients receiving
palliative radiotherapy
Notes:aDomain code;*Examined within other projects of the EU Health Monitoring Programmes (HMP); bold: High priority indicators
Social indicators
01 Educational level attained*
02 Income by decile*
03 Gini’s index*
Macro economics indicators
04 Gross domestic product*
05 Total social expenditure*
06 Total national expenditure on
health
07 Total public expenditure on
health
08 Anti-tabacco regulations
09a Public expenditure for cancer
prevention on anti-tabacco activity
09b
Total
expenditure
for
population-based cancer registries
09c Total expenditure on organized
cancer screening programmes
09d Public expenditure on cancer
drugs*
09f Public expenditure on cancer
research
09f Estimated cost for a cancer
patient
Demographic indicators
10 Age distribution in 2010, 2020
and 2030
11 Life-table quantities*
The following institutions are involved in cancer monitoring in Romania:
A Institutions under the supervision of the Romanian Health Ministry:
-Public institutions: Center for Health Statistics and Medical Documentation
(CCSSDM), Public Statistical Institution (ISP), National Institute of Research and
Development in Health (INCDS), General Directions of Medical Insurance (DGAM),
Bucharest Oncologic Institute (IOB), Cluj National Oncologic Institute (INOC),
Regional oncology sections.
-Private institutions: Dr Victor Babes Foundation, Bucharest (FVB), Center for Social
Health Politics (CPSS), SOFRECO.
B Institutions not under the supervision of the Romanian Health Ministry: National
Institute of Statistics (INS).
I Field of cancer prevention
Indicators in this field are resulting from data derived from surveys (polls) with national
impact.
Table 1-indicators on cancer prevention
Consumption of fruit&vegetables
Consumption of alcohol
Physical activity
Body Mass Index
Tabacco smokers adults
Tabacco 10-14 years
Prevalence of ex-smoker
Prevalence of ETS
Exposure to sun radiation
Prevalence of occupational exposure to
carcinogens
Available; INS-yearly survey
Available; INCDS-special survey (ESPAD)
Not available
Not available
Available; CPSS-suvey
Not available
Available; CPSS-survey
Not available
Not available
Available
Proposed actions:
I.1 To ensure the continuation of existing surveys and to initiate new surveys in the areas
not covered yet (e.g. survey regarding physical activity, BMI, ETS, exposure to sun
radiation)
I.2 To adapt the existing surveys to include the European indicators of cancer monitoring
in order to have comparability (standardization) of data.
I.3 To improve the analysis and dissemination of data resulted from health surveys,
which are necessary in planning new cancer programs.
I.4 To design some special programs that promote healthy lifestyle in children and young
people –education about prevention in cancer and early detection.
II Field of cancer epidemiology
Indicators in this field are representative for cancer burden in each country. In Romania
there exists a National Cancer Registry, whose reorganization is stipulated in the 2.2
Prevention and Control in Oncology and also in the EU Phare projects RO-2002/000586.04.11.03. This registry is located at the Center for Health Statistics and Medical
Documentation (CSSDM) and reorganized continuously; it functions in accordance with
the European guidelines, as stated in the European Network Cancer Registry (ENCR).
Areas recently identified as need-improvement in this registry:
-International Classification of Disease for Oncology (ICD-0) is not yet in use, making
comparability between countries difficult.
-Geographical coding SIRUTA, for the uniqueness of towns and right registration of
patients, is not in use.
-Personal identifier coding is not used, permitting some duplicate entries.
-There are still under-reported areas.
-There exists only a passive reporting system, with no follow-up and trace back
procedures
-The only information sources are the ONC1 form and the death certificate; there are no
pathology reports and no data regarding stage at diagnosis.
-There exists only manually collected information and a poor analysis of data (lack of
necessary software and hardware-IT infrastructure)
-The cancer registrar profession does not exist and there are no specific training activities
for people involved in collecting, processing, disseminating of data regarding cancer
burden in Romania.
Table 2-indicators of epidemiology and cancer registration
Population covered by higy quality cancer
registry
Cancer incidence rates
Cancer relative survival rates
Cancer prevalence proportions
PYLL-Person-years Life Lost due to cancer
Stage of diagnosis-% of cases with early
diagnosis
Stage of diagnosis-% of cases with a
metastatic test
Available
Available
Not available
Available
Not available
Not available
Not available
Proposed actions:
II.1 To adapt the database in accordance with ENCR and to standardize the data quality
of cancer registry. The best intervention inside this action can be to set-up a cancer
epidemiology department, inside CSSDM. This way we can assure the logistic support
necessary to undertake the adaptations and permanent cancer monitoring. It is necessary
to allocate enough human resources, create the cancer registrar profession, organize
specific training for collecting, processing and dissemination of data and allocate
financial resources for publishing a national report regularly.
II.2 To establish national incentives to stimulate the participation in European or
international cancer programs and to organize exchange visits in order to limit the
existing gaps regarding cancer epidemiology.
e.g.1 Participation in: EUROCARE, study regarding survival rates and EUROPREVAIL,
study regarding prevalence proportion.
e.g.2 Application for ICRETT fellowships at Union Internationale Contre le Cancer
(UICC), in order to participate on educational programmes regarding estimations in areas
not covered by cancer registry.
III Field of cancer screening (early detection of cancer)
Opportunistic screening
In Romania it is mandatory to report the number of undertaken test screenings for breast,
cervix, colorectal and prostate cancers, by the public medical institutions. In the private
medical sector this reports are optional. These data are gathered by the Romanian
Ministry of Health-General Direction of Medical Assistance, Mother and Child
Assistance. The opportunistic screening is offered in primary health care settings, at the
physician recommendation.
Organized screenings
In Romania, financial limitations impose the scarcity of organized screenings. Thus, the
only organized screenings were made for cervical cancer, in limited areas without
national estimates, between Jun 2002-Jun 2004.
Table 3-Indicators of cancer screening
% of women that have a mammography
% of women that have a cervical cytology
% of persons that have a colo-rectal cancer
test
Organized screening coverage
Available, but with differences
Available, but with differences
Available, but with differences
Available;
Only for cervical cancer, the only
organized screening program in Romania
Proposed actions
III.1 To promote a health survey that evaluates opportunistic screening programs in
Romania.
Inside the action it will be necessary to design a study to analyze the relationship between
screening programs and reduction of cancer site mortality (for which a systematic
screening will have been implemented).
Also, it will be necessary to provide the
financial and human resources to complete this survey.
III.2 To initiate a sub-regional organized screening program and make studies on
differences in the sub-regions involved.
IV Field of cancer diagnostic and treatment
In Romania cancer treatment is offered inside the regional oncology sections from each
Cantonal General Hospitals and affiliated ambulatory oncological services. There are two
National Oncological Institutes: Bucharest Oncology Institute, IOB and Cluj National
Oncology Institute, INOC.
The medical oncologists first diagnose the majority of cancer patients and only a minority
is diagnosed by GPs. Most of cancer patients are referred to one of the National
Oncological Institute for confirmation of diagnosis and for treatment technical facilities.
In Romania, the cancer treatment is entirely compensated through national health
insurance. From 2002, in Romania palliative care is recognized as a distinct medical
field, there are physicians trained in palliative care and palliative treatment is offered to
cancer patients at European standards. Palliative radiotherapy is available in both of the
National Oncological Institutes, but the indicator related to this treatment is not available.
Table 5-Indicators in diagnostic and cancer treatment
Delay of cancer treatment
% of radiation system in the population
% of diagnostic Computer Axial
Tomographies (CTs) in the population
Compliance with best oncology practice
Percentage of patients treated with
palliative radiotherapy
Not available
Not available
No of linear accelerators/country is known
but indicator is not calculated.
Not available
Note: The number of CTs from public
medical institutions are available at the
Ministry of Health-Medical Equipment
Direction ; lack of data from private sector
Not available
Not available
There is no epidemiological data regarding the evaluation of cancer treatment in relation
with EUROCHIP indicators and no indicators available in this field. There is a high
priority to gather these data and to adapt the database of oncology institutions registries
regarding the treatment.
V Field of macroeconomics
In Romania there are strict anti-tobacco regulations since 2002 (law No 349/2002;
Governmental Order No 13/2003; law No 275/2003).
-Smoking in public places is illegal.
-Selling tobacco to people less than 18 years of age is prohibited.
-There are technical and hygiene rules in manufacturing, transport and selling of tobacco
products.
Data: Sept 2, 2005
Dr. Iuliana Apostol; Dr. Cornelia Nitipir
EUROCHIP II, PE Romania
Victor Babes Foundation, Bucharest