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EUROCHIP-2 - The Action
EUROCHIP-2
Public Health Program
EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
www.tumori.net/eurochip
EUROCHIP2:
INEQUALITIES
IN CANCER
MANAGEMENT
Gross Domestic Product (1997) and
5-year- age- and cancer site- adjusted relative survival (women)
The area of the disk is proportional to the Total National Health Expenditure ($ PPP) in the country
$ PPP: Parity Purchasing Power per capita (US $) Sources: OECD 2002 for GDP and TNEH; EUROCARE-3 for survival
Relation between age standardised -prevalence (P), -incidence (I), and -relative
survival for all malignant neoplasms in 17 European countries, 1992
(The area of the disk is proportional to the 5-year relative survival)
OUR INDICATIONS MUST
REFER TO THE BEST
STRATEGY FOR THE
DIFFUSSION OF
BEST PRACTICE
METHODS OF EUROCHIP-2
ACTIONS
1. Knowledge: finding data sources, improvement /
standardisation of data collection
2. Choice: analyse data, compare data, find relations, find
major deficiencies
3. Promotion: design, validate and finance initiatives to
reduces cancer disparities
These phases should be looked at as part of
an iterative process
EUROCHIP: THE ORGANISATION
GS: Groups of specialists
a) Promotion of the action
at national level or
b) International domain
level
(prevention, cancer
epidemiology,
screening
care&treatment,
macro-indicators)
GS
Steering Committee
Working Team
Operational work
Panel of Experts
Methodological Group
GS
GS care and
treatment
GS
GS
GS
Standardised
methods for
collecting,
checking and
validating the
data
proposed for
each indicator
GS
Cancer
network
Methodological aspects
of the indicators
THE PROCESS APPROACH (Eurochip-2 form)
Module (columns) and profile (rows)
AIMS OF EUROCHIP-2
1. Extending the collaboration of networks on cancer (new
participating countries)
2. Establishing multidisciplinary working groups in each country
(through help of willing and determined people)
3. Analysing the behaviour of various indicators in relation to
their utility as determinants of clinical outcomes, possibly
leading to modifications (continuous consensus conference)
4. Promoting at least one important ACTION in each country (to
improve the system of cancer information and to support the
fight against cancer – i.e. reduce disparities)
5. Establishing/strengthening a health information system in cooperation with other chronic disease networks as for common
risk factor or morbidity indicators
MAIN PRESENT GOAL OF THE EUROCHIP2 NETWORK
• Organisation of national groups involving cancer
experts, institutes and associations in all countries
Members of the national groups must believe in the project and have to be
motivated in their work
These groups have to be multidisciplinary groups
• Members of the National Groups have to identify
specific problems at national levels and then make
proposals on health planning
• These proposals have to reach the maximum
consensus possible in the country
TASKS OF THE NATIONAL GROUPS
• To check the availability of the Eurochip indicators
in own country (Eurochip Questionnaire)
• To promote data collection
• To use and analyse already available data
• To identify health system deficiencies at national
level
• To propose actions against these deficiencies
• To reach the maximum consensus on actions
THE ROLES OF DOMAIN GROUPS
• To test the present quality of EUROCHIP indicators
• To detect possible actions in their specific field
• To answer specific questions at national level
• To support actions related to their specific field
EUROCHIP WORKING GROUP IS PREPARING THE
INDICATOR/ACTION MATRIX
ACTIONS - e.g.: Poland
•
Knowledge: Poland is involved in the EUROCARE studies
Action: Application for funds in order to take part to Eurocare
High Resolution Studies
•
Choice:
a) Poland has the lowest cancer survival in Europe
b) Delay of cancer treatment and type of treatment used
(Treatment Domain task:
Standard Protocols for these Studies)
•
Promotion
Action: Health planning documents suggesting the delay of
treatment and non-modern treatment as cause of the lowest
cancer survival in Europe
ACTIONS - e.g. (1): Switzerland
• Knowledge: Surveys exist, yet with no questions
on screening
Action: Introducing questions on screening in the surveys
• Choice: data are available, yet no specific
analysis is carried out
Action:To promote analysis and publication of the data
• Promotion: Disparities in cancer information due
to Canton health system
Action: To promote the creation of a National Institute of
Epidemiology
ACTIONS - e.g.(2): Switzerland
• Knowledge: There are no real data to evaluate
cancer treatment, except for the Eurocare data in
Geneva and Basel
Action: To create a database analogous to Eurocare for all
Swiss Cancer Registries
• Promotion: Disparities in fund and organisation
Action: To guarantee the long-term work of all cancer
registries
Computed Tomography Scanners and
5-year- age- and cancer site- adjusted relative survival (F)
EUROCHIP-2 POSSIBLE FUND USE
•
The funds for partners have to be used only for
personnel costs
•
The possible various uses for these funds are:
•
Organisation of the national group
•
Involvement in the Eurochip pilot studies
•
Collection of available data
•
Analysis of data
•
Creation of writings of health planning
•
Connection with health planners and politicians
EUROCHIP-2 - The Action
PANEL OF EXPERTS’ Meeting – April 11th,2005
INDICATORS ON CARE & TREATMENT
European benchmarking in cancer care
Dr Ian Kunkler
Public Health Program
EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
Care and treatment
• list of approved indicators
• Definitions of datasets required
• Guidelines for modus operandi and
timelines for national and regional
european working groups
• Use of EUROCHIP resources for project
deliverables (data collection and analysis)
• Next steps
EUROCHIP 2 – care and treatment
parameters
•
•
•
•
Provision of CT scanners
Provision of megavoltage RT units
Delays in diagnosis and treatment
Compliance with best practice
CTS EQUIPMENT
WHAT?
Number of diagnostic CT (Computed
Axial Tomography or computed
tomography scanners) systems per
1
000 000 population
WHY?
Level of availability of diagnostic
facilities
HOW?
Health Ministry or Surveys
Computed Tomography Scanners – ITALY - MACROAREAS
Source: Health for all - Italy
Note: South Italy => Low survival
RADIATION EQUIPMENT
WHAT?
Number of linear accelerators per
1 000 000 population
WHY?
Availability of treatment facilities
HOW?
Health Ministry or Surveys
RADIATION EQUIPMENT and CTS EQUIPMENT
PROCESS APPROACH
KNOWLEDGE
• Identification of availability in European countries
• Comparison of equipment information collected in
different countries
CHOICE
• Analysis of the European differences
• Finding relations with cancer outcomes
ACTION
• To promote acquisition of new equipments
Requirements for modern
radiotherapy service
• 5.5.6.0 linear accelerators per 106 pop’n
• 3-dimensional planning computer and multileaf
collimator for 3D conformal RT and/or intensity
modulated radiotherapy (IMRT)
• CT simulator
• Full complement of radiographers, physicists,
clinical oncologists to allow waiting targets to be
met
Royal College of Radiologists, London,2004
How much radiotherapy is needed
and provided
• ESTRO QUARTS PROJECT
(QUAntification of Radiation Therapy
Infrastructure and Staffing Needs
QUARTS project
• Aim : provide estimates of staffing and
infrastructure requirements for RT in EU
• Transparent link between epidemiological
data and indications for RT based on best
available evidence
• 53% of patients with cancer have
indication for radical/palliativeRT (Delaney
et al,2003)
Linac throughput
• 450 treatment courses per year
• Australia Health Technology Advisory
Committee,1996
• Swedish audit 350 courses per year
• Throughput varies with complexity,
number of fractions, tumour type and
stage
National recommendations on
linacs per 0.5 million population
•
•
•
•
UK
2.0
Spain
2.5
France
3.6
Czech Republic 1.4
Bentzen (2004)
QUARTS – data for estimates of megavoltage RT
units per countryBentzen et al
• Proportion of patients with given type of
cancer
• Incidence of cancer types in country
• RT retreatment rates
• Machine throughput (no of courses of RT
per linear accelerator per year)
Evidence based use of
radiotherapy
• Division of cancer care and epidemiology,
Kingston, Ontario (McKillop,
IJRBOP,2002)
• Swedish Council of Technology in Health
Care (Acta Oncol)
• Collaboration for Cancer Outcomes
Research and Evaluation, NSW Au
(Delaney et al)
Optimal use of radiotherapy
• Overall external beam RT needed in 53% all
cancer patients (Delaney,2003)
• Some regions of UK only 22% offered RT (2002)
• Breast (83%) but clinical use 24%-71%
• Lung (76%)
• Prostate (60%)
• Rectum (61%)
• Gynae (31%)
Radiotherapy: linac provision 2000
(Cottier,2004)
No
Linac
%
MLC
Linac/
106
pop
Pop x
106
Italy
198
34%
Holland
England France Germany
73
159
48%
3.43
57.7
363
22%
275
18%
4.59
3.21
4.70
4.42
15.8
49.4
58
81.9
?
No of linacs needed per 106 pop’n
to reproduce SBU pattern of RT usage
• Hungary
• Denmark
• Ireland
11.2
5
3.6
Limitations of QUARTS study
• Heavily reliant on Swedish and
Australasian data
• Cross validation with other data sources
valuable especially from central and
southern Europe
• Data on stage needed since could differ
between Australasian CCORE data and
EU
EUROCHIP2-QUARTS
collaboration
• Advantages:
use of existing dataset and expertise on RT
provision in 25 EU countries
EUROCHIP2 could provide data on stage to
crossvalidate QUARTS data based on
SBU and CCORE
Measuring delay between
diagnosis and first treatment
• Many ‘curative’ treatments involve
multimodality treatment (surgery,systemic
therapy,RT)
• Systemic therapy pre RT eg breast cancer
may mask delays in access to RT
• Delays in access to RT best measured
where no adjuvant chemo eg breast
conserving therapy, early larynx
cancer,early cervix ca
DELAY OF CANCER TREATMENT: CONTEXT
Phases of disease history:
• Symptoms: not accurately 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 defined
specifically site per site.
As the date of first symptoms is not intrinsically defined as an event, the
working group suggests to use the date of the first diagnosis as a reference.
The indicator is the average time between date of diagnosis and date of
first treatment
The treatment group suggests specific definitions for 5 cancer sites:
breast, colon, rectum, lung and prostate.
To provide these indicators, Cancer Registries have to collect the dates of first
treatment (either surgery, chemotherapy, radiotherapy or endocrine therapy)
DELAY OF CANCER CARE
PROCESS APPROACH
KNOWLEDGE
• Definition of disease history phases for 5 cancers: breast,
colon, rectum, lung and prostate
• Identification of countries where pilot studies need be
carried out
• Writing of pilot studies protocol
• Finding relations with cancer outcomes
CHOICE
• Analysing data coming from pilot studies
ACTION
• Promotion of the diffusion of the pilot studies
• Actions to reduce delay of cancer care
TODAY IN THE UK:
CANCER PLAN IN UK : WAITING TIMES
•
Maximum 1 month wait from urgent GP referral to treatment
guaranteed for children’s and testicular cancers and acute leukaemia
•
Maximum 1 month wait from diagnosis to treatment for breast cancer
•
Maximum 1 month wait from diagnosis to treatment for all cancers by
2005
•
Maximum 2 months wait from urgent GP referral to treatment for
breast cancer
•
Maximum 2 months wait from urgent GP referral to treatment for all
cancers by 2005
•
Cancer is the first priority for roll out of booked appointments
•
By 2004 every patient diagnosed with cancer will benefit from preplanned and pre-booked care
Clinical Standards Board for
Scotland – breast cancer examples
• Minimum of 80% of patients with diagnosis within 2/52 of
first clinic (including image-guided needle biopsy or
excision biopsy)
• Therapeutic surgery: minimum of 70% within 3/52 of first
clinic visit
• Minimum of 70% conservation rate of surgically treated
small invasive cancers (<15mm path.diameter) excluding
DCIS and multifocal disease
• Adjuvant RT: minimum of 70% within 4/52 of final
operation/chemotherapy
• Adjuvant chemotherapy: minimum of 80% with 4/52 of
final operation
COMPLIANCE WITH BEST ONCOLOGY PRACTICE
PROCESS APPROACH
KNOWLEDGE
• Update of the High Resolution Studies Protocol to
collect data for these indicators
• Identification of cancer registries where organise HR
Studies
• Collection of the data
CHOICE
• Analysing data coming from HR Studies
ACTION
• Diffusion of the results
COMPLIANCE WITH BEST ONCOLOGY PRACTICE
The indicator aims to reflect the compliance with best practices in oncology.
BREAST
- Proportion of patients receiving post-operative breast radiotherapy after breast
conserving surgery
- Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded)
COLON
- Proportion of patients with Dukes C (or TNM Stage 3) receiving adjuvant
chemotherapy
- Proportion of patients with Dukes B (or TNM Stage 2) not receiving adjuvant
chemotherapy
RECTUM
- Proportion of patients receiving pre-operative radiotherapy
LUNG
- Proportion of patients with non small cell undergoing radical surgery
- Proportion of patients undergoing staging with thoracic CT scanning
CERVIX
- Proportion of FIGO-stage III/IVreceiving combined chemo-radiotherapy
- Proportion of patients with FIGO-stage “Ia2” and “Ib” undergoing
hysterectomy with pelvic lymphadentectomy (WERTHEIM-MEIGS hysterectomy)
Guidelines
• For which parameters of best practice as defined by
EUROCHIP2 is data routinely collected in each EU
country for breast,colon,lung, rectum, lung, cervix at
national/regional level?
• Is this data accessible to EUROCHIP (ethical
considerations, confidentiality)?
• Proposals for data not collectable and/or not accessible
• Does EUROCHIP2 have necessary resources for data
collation and analysis (eg how should per country
funding best be used?)
PROPORTION OF PATIENTS TREATED WITH PALLIATIVE
RADIOTHERAPY
WHAT?
Number of patients who have received
palliative radiotherapy
WHY?
Quality of life for incurable cancer
patients
HOW?
Survey on radiotherapy units
Requirements for modern
radiotherapy service
• ‘Unfortunately there is not a single
department in the UK that meets all
these requirements’
Royal College of Radiologists,2004
•
•
•
•
•
Differences in palliative RT for bone
metastases in W.Europe (Lievens et
al,2000)
Questionnaire survey of 565 RT centres
205 centres responded (36%)
Most common RT schedule 30 Gy in 10
fractions
largest centres used shorter fractionation
and less complex treatments
Level 1 evidence that single fractions as
effective as multiple fractions
Lung cancer waiting times and
tumour growth
• Prospective audit of 29 lung cancer patients
awaiting radical (curative) radiotherapy
• Comparison of tumour size on diagnostic and
RT planning scans
• 2 progressed so unfit for RT, 4 tumours became
too large for radical RT
• 21% of patients became incurable
• Median time Ist hospital visit to starting RT= 94
days (range 35-187)
O’Rourke N Clin Oncol 2000;12:141-4
Conclusions
• Collaboration needed with ESTRO QUARTS
project for RT equipment and palliative RT
provision
• Engage the oncology community
• Use of high resolution studies
• Identification of:
(i) provision of diagnostic CT scanners
(ii) date of diagnosis and date of first treatment
(iii) national/european audit data on compliance
with evidence based guidelines
Reimbursement for radiotherapy in
Poland
• •Until 1999 National Health system based
on block budget (no fee for patient, nor for
service)
• •From1999:
• •Fee for patient and fee for service.
• •Curative 1000 –2300 E
• •Palliative 500 E
• •Brachytherapy 500 –1000 E
EUROCHIP-2 - The Action
PANEL OF EXPERTS’ Meeting – April 11th,2005
DECISIONS
Public Health Program
EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
Clinical Standards Board for
Scotland – breast cancer examples
• Minimum of 80% of patients with diagnosis within 2/52 of
first clinic (including image-guided needle biopsy or
excision biopsy)
• Therapeutic surgery: minimum of 70% within 3/52 of first
clinic visit
• Minimum of 70% conservation rate of surgically treated
small invasive cancers (<15mm path.diameter) excluding
DCIS and multifocal disease
• Adjuvant RT: minimum of 70% within 4/52 of final
operation/chemotherapy
• Adjuvant chemotherapy: minimum of 80% with 4/52 of
final operation
HIGH RESOLUTION STUDIES (HR) vs EUROCHIP
COULD WE USE BREAST HR FORMS TO COLLECT DELAY INDICATOR?
• Dates in Breast HR form are not sufficient
• Pilot studies in 3-4 Cancer Registries (CR) in order to verify if it is possible
to have dates different from date of diagnosis today collected by CRs
• To enlarge the UK procedures to other countries: is it possible?
• First hospital clinic visit (first hospital contact)
• Date of positive mammography
• Date of first microscopical diagnosis (citology, biopsies)
• Date of first treatment (surgery, systemic therapy or radiotherapy) –
ALREADY PRESENT IN HR FORM
• PS Menu of data sources
HIGH RESOLUTION STUDIES (HR) vs EUROCHIP
COULD WE USE COLON HR FORMS TO COLLECT DELAY INDICATOR?
• Pilot studies in 3-4 Cancer Registries (CR) in order to verify if it is possible
to have dates different from date of diagnosis today collected by CRs
• Dates relevant to delay to collect:
• First hospital clinic visit (first hospital contact)
• Date of colonoscopy-sigmoidoscopy or barium enema
• Date of first microscopical diagnosis (citology, biopsies)
• Date of first treatment (surgery, systemic therapy or radiotherapy) –
ALREADY PRESENT IN HR FORM
• information on complete TNM
• information on elective or emergency surgery
• PS Menu of data sources: CR, HR, clinical notes, screening files,
oncology-surgery-radiotherapy-pathology-laboratory-radiology
department records, hospital or outpatient discharge, others to be
specified
• ask to all EUROCHIP participants (by national groups)
COMPLIANCE WITH BEST ONCOLOGY PRACTICE
The indicator aims to reflect the compliance with best practices in oncology.
BREAST
- Proportion of patients receiving post-operative breast radiotherapy after breast
conserving surgery
- Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded)
COLON
- Proportion of patients with Dukes C (or TNM Stage 3) receiving adjuvant
chemotherapy
- Proportion of patients with Dukes B (or TNM Stage 2) not receiving adjuvant
chemotherapy
RECTUM
- Proportion of patients receiving pre-operative radiotherapy
LUNG
- Proportion of patients with non small cell undergoing radical surgery
- Proportion of patients undergoing staging with thoracic CT scanning
CERVIX
- Proportion of FIGO-stage III/IVreceiving combined chemo-radiotherapy
- Proportion of patients with FIGO-stage “Ia2” and “Ib” undergoing
hysterectomy with pelvic lymphadentectomy (WERTHEIM-MEIGS hysterectomy)
TODAY IN UK:
CANCER PLAN IN UK: CARE & TREATMENT
•
Extension of guidance programmes to all cancers
•
Establishment of specialist team
•
Care of all cancer patients will be reviewed by specialist team
•
Monitoring progress to achieve standards
•
National cancer datasets
•
Strenghtening cancer registries
•
Improved information for patients
•
New internet resources for patients
•
Developping guidance for supportive care
•
Extra subsidizing for hospices and specialist palliative care services