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Indicators for the evaluation of the impact of the
Cancer Plan 2008-2010
REVIEWING INDICATORS FOR EVALUATION OF THE BELGIAN CANCER PLAN 2008-2010
Prof. dr. Elke Van Hoof
Eline Remue, PhD
Ir. Liesbeth Lenaerts, PhD
Ellen De Wandeler
Benoit Mores
Jelle Goolaerts
Depotnummer:
1
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Authors: Prof. dr. Elke Van Hoof and ir. Liesbeth Lenaerts, PhD
Please cite this document as follows: VAN HOOF, E. and LENAERTS, L. 2011. Indicators for the
evaluation of the impact of the cancer plan 2008-2010: reviewing indicators for evaluation of the
belgian cancer plan 2008-2010, Scientific Institute of Public Health, Belgian Cancer Center , xxp.
2
List of abbreviations
ALND
CEA
CE-CT
CRM
CT
DCIS
ECHI
ECHIM
ETS
EUROCARE
EUROCHIP
FNAC
FU
GDP
HCQI
HMP
IARC
KCE
MDT
MeSH
MRI
NCCP
OECD
PET
PM10
TNEH
WHO
axillary lymph node dissection
carcinoembryonic antigen
contrast-enhanced computed tomography
circumferential resection margin
computed tomography
ductal carcinoma in situ
European Community Health Indicators
European Community Health Indicators Monitoring
environmental tobacco smoke
European cancer registry-based study on survival and care of cancer patients
European Cancer Health Indicator Project
fine needle aspiration cytology
fluorouridine
gross domestic product
Health Care Quality Indicator
Health Monitoring Program
International Agency for Research on Cancer
Belgian Health Care Knowledge Centre
multidisciplinary team
Medical Subject Heading
magnetic resonance imaging
national cancer control plan
Organisation for Economic Co-operation and Development
positron emission tomography
particulate matter = 10µ3
total national expenditure on health
World Health Organisation
3
TABEL OF CONTENT
List of abbreviations ..................................................................................................................... 3
INTRODUCTION ............................................................................................................................ 5
RESULTS ....................................................................................................................................... 7
1. QUALITY INDICATORS FOR THE EVALUATION OF CANCER CARE RESULTING FROM A SYSTEMATIC
LITERATURE SEARCH..................................................................................................................... 7
2. CANCER HEALTH CARE QUALITY INDICATORS PROPOSED BY PROFESSIONAL ORGANISATIONS . 11
2.1. Organisation for Economic Co-operation and Development (OECD) ............................................ 11
2.2. European Cancer Registry-based study on survival and care of cancer patients (EUROCARE) ..... 11
2.3. CONCORD: Cancer survival in five continents ................................................................................ 11
2.4. European Cancer Health Indicator Project (EUROCHIP) ................................................................ 13
2.5. European Community Health Indicators Monitoring (ECHIM)....................................................... 15
2.6. World Health Organisation (WHO)................................................................................................. 16
2.7. Belgian Health Care Knowledge Centre (KCE) ................................................................................ 22
CONCLUSION.............................................................................................................................. 27
References ................................................................................................................................. 29
4
INTRODUCTION
The evaluation of a Cancer Plan is a critical and central component of the organisation and
management of the fight against cancer. First, the evaluation process assesses the progress made in
terms of the objectives that have been put forward. Secondly, the identification of strengths and
gaps of the current Cancer Plan may contribute to future adjustments and additional
recommendations. The evaluation of a Cancer Plan preferably focuses on the following three
components: (1) the content of actions and measures included; (2) the way the Cancer Plan and its
actions are implemented and (3) the results of the actions in terms of health outcomes.1
This document is one of the reports published in the context of the evaluation of the implementation
of the Cancer Plan 2008-2010. The evaluation of the implementation was carried out in 6 consecutive
phases:
1. Evaluation of the implementation of the Cancer Plan 2008-2010: identification of a
methodology
2. Evaluation of the implementation of the Cancer Plan 2008-2010: literature review
3. Evaluation of the implementation of the Cancer Plan 2008-2010: feasibility analysis of the
indicators identified in preparation of the evaluation of the Cancer Plan 2008-2010
4. Evaluation of the implementation of the Cancer Plan 2008-2010: Results 2011
5. Evaluation of the implementation of the Cancer Plan 2008-2010: qualitative evaluation by
means of a Limesurvey
6. Evaluation of the implementation of the Cancer Plan 2008-2010: summary
The above mentioned reports can be obtained through our website (www.ekanker.be) or via email
([email protected]).
The aim of this review was to identify valid indicators to analyse the progression of the Belgian
Cancer Plan 2008-2010 as well as the impact of actions specified in the Belgian Cancer Plan, by
means of a systematic review of the existing literature.
REVIEW METHOD:
PubMed was searched to identify published and validated quality indicators (publication period until
November 2011) for cancer care using the Medical Subject Heading (MeSH) terms ‘quality indicators’
and ‘health care’ combined with terms for ‘cancer’. Only publications containing English abstracts for
which a free full-text was available were included and only general quality indicators related to
cancer care were withheld (reviewing indicators on technical aspects of oncology care or physician’s
5
performance fell beyond the scope of this review). The literature search identified 565 titles, of
which 103 were in English language containing links to a free full text. We also conducted an
extensive Internet search of professional organisations seeking guidelines and other grey literature
(i.e. not published in peer-reviewed journals) and added relevant indicators to the list of indicators
resulting from the literature search. The selection process was performed independently by 2
researchers.
6
RESULTS
1. QUALITY INDICATORS FOR THE EVALUATION OF CANCER CARE RESULTING FROM A SYSTEMATIC
LITERATURE SEARCH
We searched PubMed for scientific literature (publication period until November 2011) using the
MeSH terms ‘quality indicators’ and ‘health care’ combined with terms for ‘cancer’. Only publications
containing English abstracts and a link to a free full text were included. In addition, an extensive
Internet search of grey literature was performed and relevant indicators were added to the list of
indicators resulting from the scientific literature search. Subsequently, we selected those quality
indicators with regard to oncopolicy and those that are useful for the evaluation of general cancer
care. Indicators on technical aspects of oncology care or physician’s performance were excluded
from the overview. Next, scientific references that were also referred to by professional
organisations (see Table 2 to 6) were removed from the indicator list. The resulting overview of
quality indicators is shown in Table 1.
TABLE 1. OVERVIEW OF CANCER CARE QUALITY INDICATORS RESULTING FROM A SCIENTIFIC AND GREY LITERATURE
SEARCH
INDICATOR
TYPE
Process
Process
INDICATOR
Preoperative histological confirmation of diagnosis of breast cancer
Appropriate axillary dissection (breast cancer)
Patients with sentinel lymph node biopsy (SLNB) (breast cancer)
Complete staging data (breast cancer)
Safety distance between and resection margin (breast cancer)
HER-2/neu assessment
Specimen imaging (breast cancer)
Hormone receptor assessment (breast cancer)
Guideline-concordant endocrine therapy in hormone receptor-positive breast
cancer patients
Guideline-concordant adjuvant and neoadjuvant chemotherapy
Use of appropriate standard regimens in chemotherapy for breast cancer
Adjuvant combination chemotherapy with anthracyclines and/or taxanes for
breast cancer
Percentage of breast cancer patients in clinical trials
Radiotherapy after breast conserving surgery
Radiotherapy after breast conserving surgery for ductal carcinoma in situ
(DCIS)
Radiotherapy after mastectomy
Indication for breast conserving surgery
Proportion of breast cancer patients discussed in the multidisciplinary breast
cancer team before surgery
Proportion of breast cancer patients discussed in the multidisciplinary breast
cancer team after surgery
Proportion of breast cancer patients who first visited the outpatient clinic at the
7
REF.
6
14
Process
Process
latest on day seven after contact
Proportion of breast cancer patients who received the pathology diagnosis at
the latest on day seven after the first visit to the outpatient clinic
Proportion of breast cancer patients who underwent surgery at the latest on
day 21 after the patient received the pathology diagnosis (exclusion: patients
with previous treatment other than surgery)
Proportion of breast cancer patients discharged at the latest on day seven after
hospital admission
Proportion of successful sentinel node procedures (sentinel nodes were
detected during the surgical procedure for breast cancer)
Proportion of axillary lymph node dissections (ALND) whereby at least 10 lymph
nodes were examined (breast cancer)
Proportion of breast cancer patients with only one primary surgical intervention
(either breast conserving surgery or mastectomy)
Proportion of in situ breast cancers
4
Proportion of in situ breast cancers (50 –69 years)
Proportion of invasive breast cancers with tumor size
Median tumor size for invasive breast cancers (mm)
Mean tumor size for invasive breast cancers (mm)
Proportion of invasive breast cancers with negative lymph node
Proportion of invasive breast tumors with stage I
Proportion of invasive breast tumors with stage II+
Proportion of women aged over 50 who received bilateral mammography 3
7
months before surgery
Proportion of breast cancer patients who have diagnosis in cytology and
histology before surgery
Proportion of breast cancer patients who were discussed by a multidisciplinary
team (MDT)
Proportion of zero-stage breast cancer patients with 10 or more lymph nodes
on pathology report
Proportion of stage I and II patients who undergo breast conserving surgery
Proportion of breast cancer patients with pathology report of tumor size in the
medical record after surgery
Proportion of invasive breast cancer after surgery with 10 or more lymph nodes
removed on pathology report
Proportion of invasive breast cancer patients with oestrogen receptor analysis
results in the medical record
Proportion of patients with invasive cancer who receive radiation treatment
after breast conserving surgery
Proportion of breast cancer women aged less than and equal to 50 years (premenopausal) with positive lymph node receiving adjuvant chemotherapy
Proportion of breast cancer women aged greater than 50 years (postmenopausal) with positive lymph node receiving adjuvant hormone therapy or
chemotherapy
8
Outcome
Process
Outcome
Annual mammography rate for breast cancer patients after treatment
Five-year local recurrence rate after surgery for breast cancer
Five-year disease-free survival rate following breast cancer
Five-year overall survival rate following breast cancer
Uptake of screening and incidence of interval breast cancers in populations
2
covered by Breast Check (Ireland)
Percentage of women, in the target age-groups, for whom population based
cervical cancer screening is available
Percentage uptake of screening in areas covered by the Irish Cervical Screening
Programme
Percentage of patients with cancer whose care is consistent with national,
multidisciplinary guidelines, as developed by Health Information & Quality
Authority (Ireland)
Waiting times from diagnosis to definitive treatment for major cancers
Percentage of patients waiting for longer than one month from the time of
diagnosis to the start of treatment
Percentage of breast cancer patients undergoing therapeutic surgical
procedures who do so in a designated breast cancer treatment centre
Mortality rates:
 Direct Age Standardised Mortality rate (5-year, all ages) for all causes of
cancer
 Direct Age Standardised Mortality rates (5-year, all ages) for the top six
Causes of cancer mortality
Percentage of cancer patients seen by a member of a Specialist Palliative Care
Team
Percentage of cancer patients dying by place of death (home, hospice, hospital)
Percentage of cancer patients participating in clinical trials
Incidence of cancer (total and per specific cancer type)
Survival (five-years relative survival) and quality of life
Mortality
Percentage of the population who are smokers by age, sex and social class
Percentage of the adult and childhood populations who are overweight or
obese by age, sex and social class
Percentage of the population who consume more than the recommended
alcohol weekly limits by age, sex and social class
Incidence of major site-specific cancers, to include at a minimum lung, breast,
prostate and colorectal cancer
Incidence of invasive and in-situ melanoma
Trends in quality of life for cancer patients, determined by ongoing quality of
life measurement, at different stages in the care pathway for major cancers
Stage of presentation of common cancers: appropriate stage indicators should
be defined for lung, breast, colorectal and cervical cancers
Survival rates:
 5-year Relative Survival Rate for Breast Cancer
9
1-year Relative Survival Rate for Lung Cancer
 5-year Relative Survival Rate for Prostate Cancer
 5-year Relative Survival Rate for Colorectal Cancer
national gross product
scientific production
breast screening participating rate
smoking rate
all cancer mortality rate (male population),
Five-year relative survival for colorectal cancer
life expectancy at birth
Attendance breast cancer screening program (%)
Recalls rate breast cancer screening program (%)
Histological confirmation rate following breast cancer screening (%)
Rate (%) Malignant (breast cancer screening)
Rate (%) In situ (breast cancer screening)
Rate (%) Stage I (breast cancer screening)
Rate (%) Stage II+ (breast cancer screening)
Positive predictive value of mammography
Positive predictive value of histological confirmation (breast cancer screening)
Benign to malignant biopsy ratio (breast cancer screening)

Structure
Process
Outcome
Process
10
5
13
2. CANCER HEALTH CARE QUALITY INDICATORS PROPOSED BY PROFESSIONAL ORGANISATIONS
2.1. Organisation for Economic Co-operation and Development (OECD)
The OECD is an international organisation that promotes policies for the improvement of the
economic and social well-being of people around the world by providing a forum for governments to
share experiences and to seek solutions to common problems. The OECD sets up international
standards on socio-economic related themes based on independent and evidence-based analytical
work. With regard to health care, the OECD’s Health Care Quality Indicator (HCQI) Project was
established in order to develop a common set of indicators to assess the quality of health care
delivered across OECD member countries. The key criteria for selecting indicators were the
importance of what is being measured, the scientific soundness (i.e. validity, reliability, and explicit
evidence) of the measures, and their feasibility (i.e. data needs and cost of measurement)1. In the
particular context of cancer care, a questionnaire on cancer screening and systems of cancer care
was developed (in collaboration with the coordinators of the CONCORD and the EUROCARE studies,
see below) in order to explore the relation between resources, process quality, governance and
survival in patients with breast, cervical, colorectal and lung cancers. This questionnaire was
generated using evidence of best practice from literature reviews and experience of best practice in
collecting health system characteristics information. All OECD quality indicators for international
comparison of cancer care are listed in Table 2.
2.2. European Cancer Registry-based study on survival and care of cancer patients (EUROCARE)
EUROCARE (European cancer registry-based study on survival and care of cancer patients), set up in
1998 by the European Community, is a Europe-wide concerted action to comparatively analyse
survival data from European population-based cancer registries. This cancer epidemiology research is
coordinated by the Istituto Nazionale dei Tumori (Milan, Italy) and the Istituto Superiore di Sanità
(Rome, Italy) and has thus far provided numerous comprehensive publications on cancer patient
survival in Europe resulting from 4 major projects: EUROCARE-1 (analysis of survival data on patients
diagnosed from 1978 to 1984), EUROCARE-2 (from 1978 to 1989), EUROCARE-3 (from 1983 to 1994)
and EUROCARE-4 (from 1988 to 2002)3, 15. EUROCARE survival data have been used as indicators of
progress in cancer control in the EUROCHIP project (see below).
2.3. CONCORD: Cancer survival in five continents
The CONCORD study was established in 1999 by the World health Organisation (WHO), OECD, Cancer
Research UK and the US Centers for Disease Control and Prevention as an extension of the
EUROCARE study. CONCORD provides a worldwide systemic analysis of differences in populationbased cancer survival. The first study assessed survival data of adults diagnosed with cancer of the
breast, colon, rectum or prostate during 1990-1994, by use of standard-quality procedures, standard
analytic methods and a single, centralised analysis of individual tumor records obtained from cancer
registries in five continents8. The second CONCORD (CONCORD-2) study will launch in January 2012
and will cover 10 cancers in adults, and childhood leukaemia, with data from cancer registries from
50 countries on patients diagnosed during the period 1995-2009. In this way, CONCORD contributes
to the WHO Action Plan for non-communicable diseases, by promoting international partnerships to
evaluate the effectiveness of cancer control at national, regional and global levels
11
TABLE 2. OECD HEALTH CARE QUALITY INDICATORS WITH REGARD TO CANCER CARE
TYPE OF
INDICATOR INDICATOR
Process
Cervical cancer screening rates in women aged 20-69 years
Mammography screening rates in women aged 50-69 years
Characteristics of cancer screening program (interval, target population, low
age, coverage, national rollout, provision free of charge)
Referral time (general practitioner to specialist)
Waiting time (diagnosis to treatment) (should be below 30 days)
Provision of optimal treatment (combination of surgery, radiotherapy and
chemotherapy if patient is diagnose early at a localised stage)
Clinical use of innovative cancer drugs such as Herceptin (trastuzumab),
Avastin (bevacizumab), Aromasin (exemestane), Femara (letrozole), Arimidex
(anastrozole), Evista (raloxifene), Erbitux (cetuximab), Eloxatin (oxaliplatin),
Camptosar (irinotecan) and Xeloda (capecitabine)
Setting up cancer-specific targets
Introducing a comprehensive national cancer control plan (NCCP)
Making additional funding available to achieve these targets
Assigning the lead person or organisation to oversee the implementation
Putting quality assurance mechanisms in place for cancer care
Coordinating care and developing networks for service delivery
Identifying the key milestones and timeframes
Monitoring the progress
Making someone responsible if targets are not met
National guidelines (screening, diagnosis, treatment)
Case management (MDT)
Accreditation of health professionals
Licensing of hospitals
Outcome Mortality rates (all, breast, cervical, colon, lung and prostate cancers)
Five-year relative survival rates for cervical, breast and colorectal cancer
Tobacco consumption among adults
Adult population smoking daily (%)
Change in smoking rates (%)
Females smoking daily (%)
Males smoking daily (%)
Alcohol consumption among adults
Change in alcohol consumption (%)
Structure Total national expenditure on health (TNEH)
GDP per capita adjusted for purchasing power parity
Computer tomography (CT) scanner units per million people and GDP
Positron emission tomography (PET) scanners per million people
Oncologists per million people
Comprehensive treatment centres per million people
12
REF.
12, 13
12, 13
13
13
13
13
13
13
13
13
13
13
13
13
13
13
13
13
13
13
12, 13
12, 13
12
12
12
12
12
12
12
13
13
13
13
13
13
2.4. European Cancer Health Indicator Project (EUROCHIP)
The European Cancer Health Indicator Project (EUROCHIP) was launched in 2001 by the European
Commission as a contribute to the Health Monitoring Program (HMP) in order to produce a
comprehensive list of health indicators for the monitoring of cancer and cancer management in
Europe. The first EUROCHIP project, EUROCHIP-1 (2001-2003), delivered a comprehensive list of
cancer health indicators for the cancer domains of prevention, screening, and care (reference 10 and
Table 3). The development of these indicators was based on criteria such as reliability, comparability,
ease of collection and national representativeness. The consecutive projects, EUROCHIP-2 and
EUROCHIP-3 extended this work and used the list of indicators to evaluate international variations in
cancer survival as reported within the EUROCARE projects.
TABLE 3. LIST OF EUROCHIP INDICATORS
INDICATOR DOMAIN
INDICATOR
Prevention
Lifestyle
Consumption of fruit and vegetables
Consumption of alcohol
Body mass index distribution in the population
Physical activity
Tobacco survey:
 prevalence of tobacco smokers among adults;
 tobacco smokers among 10-14 years old;
 ex-smokers
Environmental
Exposure to environmental tobacco smoke (ETS)
and
Exposure to sun radiation
occupational
PM10 (particulate matter=10µ3) emissions
risk
Indoor exposure to radon
Prevalence of occupational exposure to carcinogens
Exposure to asbestos: mesothelioma incidence and
mortality trends
Medicaments
Prevalence of use of hormonal replacement treatment
drugs
Epidemiology
Population covered by Cancer Registries
and Cancer
Cancer incidence rates trends and projections
Registration
Cancer relative survival rates, trends and projections
Cancer prevalence proportions, trends and projections
Cancer mortality rates, trends, projections and personyears of life lost due to cancer
Stage at diagnosis: percentage of a) cases with early
diagnosis and b) cases with a metastatic test
Screening
Screening
Percentage of women that have undergone a
examinations
mammography (breast cancer)
Percentage of women that have undergone a cervical
cytology examination (cervical cancer)
Percentage of persons that have undergone a colo-rectal
cancer screening test
13
REF.
10
National
evaluation in
HMP of
organized mass
screening
process
indicators
Treatment
and clinical
aspects
Health system
delay
Resources
Treatment
Palliative care
Social and
macroeconomic
variables
Social indicators
Macro
economic
indicators
Demographic
indicators
Organized screening coverage
Screening recall rate
Screening detection rate
Screening localized cancers
Screening positive predictive value
Screening benign/malignant biopsy ratio
Screening interval cancers
Screening specificity
Delay of cancer treatment (pilot studies)
Percentage of radiation systems in the population
Percentage of diagnostic Computed Axial Tomography in
the population
Percentage of PETs on population (for future)
Percentage of magnetic resonances on population (for
future)
Compliance with best oncology practice
Use of morphine in cancer patients
Percentage of patients receiving palliative radiotherapy
Educational level attained
Income by decile
Gini’s index
GDP
Total social expenditure
TNEH
Total public expenditure on health
Anti-tobacco regulations
Total expenditure for population-based cancer registries
Total expenditure on organized cancer screening
programmes
Public expenditure on cancer drugs
Total expenditure on cancer research
Estimated cost for a cancer patient
Age distribution in 2010, 2020 and 2030
Life-table quantities
14
2.5. European Community Health Indicators Monitoring (ECHIM)
The European Community Health Indicators Monitoring (ECHIM) project was launched by the
European Commission in 2005 in order to advance health monitoring in the European Union by
developing relevant, valid and comparable health indicators and the subsequent implementation of
these indicators in the European Union Member states. This should ultimately allow the comparison
of health data at an international level. The development of the ECHIM list of health indicators was
based on the European Community Health Indicators (ECHI) shortlist. The indicators presented in the
ECHIM report9 and which are relevant for cancer health care, are listed in Table 4.
TABLE 4. INDICATORS FROM THE ECHI SHORTLIST RELEVANT FOR CANCER HEALTH CARE
INDICATOR
DOMAIN
INDICATOR
REF.
Demographic and Population by education
9
socio-economic
Population below poverty line and income inequality
factors
Health status
Smoking-related deaths
Cancer incidence
Determinants of
Body mass index
health
Regular smokers
Pregnant women smoking
Total alcohol consumption
Hazardous alcohol consumption
Consumption/availability of fruit
Consumption/availability of vegetables
Physical activity
PM10 exposure
Health
Breast cancer screening
interventions:
Cervical cancer screening
health services
Colon cancer screening
Medical technologies: magnetic resonance imaging (MRI) units and CT
scans
Expenditures on health
Survival rates cancer
Equity of access to health care services
Cancer treatment quality
Health
Policies on ETS exposure
interventions:
Policies on healthy nutrition
health promotion Policies and practices on healthy lifestyles
15
2.6. World Health Organisation (WHO)
The WHO is the directing and coordinating authority for health within the United Nations. This
agency monitors and addresses health trends, provides leadership on global health matters by
setting norms and standards, and provides technical support to countries around the world. Findings
of the International Agency for Research on Cancer (IARC), which is part of the WHO and which
coordinates and conducts both epidemiological and laboratory research on cancer, are translated
effectively into timely policies for cancer control. Since the early 1980’s the WHO has been
promoting NCCPs within the prevention and control of non-communicable diseases in order to assist
countries in building and reinforcing their capacity for planning and implementing effective
programs. The first part of Table 5 summarizes the WHO core health indicators that are also of
importance in the specific context of the evaluation of cancer care. The remainder of Table 5
presents examples of indicators that have been put forward by the WHO to assess the performance
of NCCPs.
TABLE 5. WHO HEALTH CARE QUALITY INDICATORS WITH REGARD TO CANCER CARE
TYPE OF
INDICATOR
INDICATOR
WHO Core Health Indicators
Structure
External resources for health as percentage of total expenditure on health
General government expenditure on health as percentage of total
expenditure on health
General government expenditure on health as percentage of total
government expenditure
Out-of-pocket expenditure as percentage of private expenditure on health
Per capita government expenditure on health at average exchange rate
Per capita government expenditure on health
Per capita total expenditure on health
Per capita total expenditure on health at average exchange rate
Private expenditure on health as percentage of total expenditure on health
Private prepaid plans as percentage of private expenditure on health
Social security expenditure on health as percentage of general government
expenditure on health
Total expenditure on health as percentage of GDP
Outcome
Age-standardized mortality rate for cancer (per 100 000 population)
Age-standardized mortality rate for non-communicable diseases (per 100 000
population)
Years of life lost to non-communicable diseases (%)
Per capita recorded alcohol consumption (litres of pure alcohol) among adults
(≥15 years)
Prevalence of current tobacco use among adolescents (13-15 years) (%) both
sexes
Prevalence of current tobacco use among adolescents (13-15 years) (%)
female
Prevalence of current tobacco use among adolescents (13-15 years) (%) male
16
REF.
17
Examples of quality dimensions that can be used to evaluate the performance of a national cancer
control program
Process
Level of satisfaction of providers and patients with tobacco cessation 18
counselling in the workplace
Level of satisfaction of providers and patients with cervical cancer screening
program
Level of satisfaction of providers and patients with the treatment for curable
cancers
Level of satisfaction of providers and patients with palliative care program
Percentage of providers and patients who are smokers that have access to
tobacco cessation counselling
Percentage of at risk women with a Pap smear taken in the last 5 years
Timeliness of diagnosis and treatment for patients referred for having an
abnormal cytology (cervical cancer screening)
Percentage of patients with curable cancers that receive adequate treatment
Timeliness of diagnosis and treatment of curable cancer cases referred for
having warning signs
Level of morphine and other opioids consumption during palliative care
Percentage of cancer patients with advanced cancer who have access to
palliative care services
Percentage of patients with a non-communicable disease that are assessed
about their tobacco smoking status
Quality of Pap smears taken by primary health care workers and
gynaecologists
Percentage of patients with pre-cancerous cervical lesions that are treated
with non-invasive procedures
Percentage of patients that are treated for curable cancers according to
guidelines
Percentage of patients who receive palliative care according to guidelines
Percentage of primary health care workers with the necessary skills to give
counselling on smoking cessation
Continuing training of primary health care workers and laboratory staff
regarding Pap smears collection, processing and analysis
Quality assurance activities for diagnosis and treatment of the most common
cancers
Percentage of primary healthcare workers with the skills to provide basic
palliative care
Plans implemented for avoiding relapse in ex-tobacco smokers
Plans for follow-up of target population to repeat cervical cancer screening
every 5 years
Follow-up mechanisms for patients treated for non-invasive cervical cancer
Mechanisms for long-term follow-up of patients treated for curable cancers
Percentage of patients that have access to trained health care worker in
palliative care in their community
17
Outcome
Tobacco cessation rates among smokers with low to severe addiction
Changes in stage distribution of cervical cancer
Incidence of invasive cancer
Mortality from invasive cancer
Overall and stage-specific survival rates from curable cancers
Improved control of symptoms in patients with advanced cancer
Improved quality of life in palliative care
Structure
Costs of counselling for smoking cessation
Percentage of Pap smears taken from at risk women
Comparative data on cost of treatment of curable cancers
Reduction in hospital stays for treatment of curable cancers
Reduction of invasive procedures for palliative care
Reduction in hospital stays for palliative care
Regulations to avoid passive smoking in healthcare settings
Regulations to protect laboratory staff
Radiation protection for patients and providers in radiotherapy services
Measures to avoid abuse of opioids
Examples of structure, process and outcome indicators, and their associated standards,
for evaluation of a cervical cytology screening program
Structure
Organised cervical cancer screening program included in the national cancer
19
control policy
Early detection, diagnosis and treatment services for cervical cancers
screening included in the health insurance package
Network of health-care providers across the different levels of care
Network of community leaders trained and motivated to provide good quality
services
Process
Number of women in the target group (35-64 years of age)
Proportion of women in the target group that have been screened in last 3
years (coverage)
Proportion of screening tests done in the target population as specified under
the program
Proportion of screening tests that needed to be repeated because they were
inadequate
Proportion of primary health-care providers monitored for adequate
administration of the test
Proportion of test-positive women in the screened group
Proportion of test-positive women who receive their screening test result
within 3 weeks
Proportion of test-positive women who are referred and reach a specialized
clinic for diagnosis
Proportion of test-positive women who receive confirmation of diagnosis
within 1 month
Proportion of test-positive women diagnosed with precancerous lesions or
cancer
18
Short-term
outcomes
Proportion of women diagnosed with precancerous lesions or cancer who
receive appropriate treatment within 2 months of diagnosis
Ratio between the number of early cancer cases (cancer in situ, stage I)
detected by screening and the number of cancers diagnosed during the
screening intervals (false negatives missed during screening and fast growing
s that developed during the screening intervals)
Proportion of cased diagnosed in early stages
Overall 5-year survival rate for cervical cancer
Mediumterm
outcomes
(5 years)
Long-term Invasive cervical cancer incidence rates
outcomes
Invasive cervical cancer mortality rates
(10 years)
Examples of structure, process and outcome indicators, and their associated standards,
for evaluation of a diagnosis and treatment program for common curable cancers
Structure
Policies and regulations include diagnosis and treatment as a key component 20
of the national cancer control plan
Funding and service delivery models established to support the provision of
cancer diagnosis and treatment for all patients with curable cancers
List of essential medicines for the complete treatment of curable cancers
requiring chemotherapy agents and other medicines
network of health workers across the different levels of care trained to refer
patients without delay or to provide good diagnostic and treatment services
hospital registries for monitoring and follow-up of all cancer patients targeted
by the program, linked to the early detection information system as needed
educational courses that provide
 core knowledge and skills to practising health-care professionals across
all levels of care regarding referral of cancer cases and provision of
palliative care;
 expert knowledge and skills to selected health-care professionals on
providing diagnosis and treatment services at the secondary and
tertiary levels, as needed
 undergraduate oncology education to health-care professionals
(doctors, nurses, pharmacists, social workers) focusing on awareness
of early signs and symptoms of common detectable cancers
 education to patients and family caregivers
Process
Number of cases detected early where patients get timely confirmation of
diagnosis
Number of curable cancer patients getting timely treatment
Number and type of trained health-care professionals at the secondary and
tertiary levels of care qualified to provide diagnosis and treatment for curable
cancers according to established standards
Proportion of patients whose cancers are detected early who get timely
19
diagnosis
Proportion of patients with diagnosed curable cancers who get timely
treatment
Proportion of curable cancer patients who get adequate treatment according
to established guidelines
Proportion of curable cancer patients who abandon or do not complete
treatment, by age, sex and socioeconomic group
Proportion of curable cancer patients and their family caregivers who get
psychosocial support throughout the course of the disease
Proportion of patients and family caregivers receiving relevant education
Short-term
Proportion of curable cancer cases diagnosed in early stages
outcomes
MediumOverall 5-year survival rates for curable cancers
term and
long-term
Overall 10-year survival rates for curable cancers
outcomes
(5 and 10
Mortality rates for curable cancers
years)
Examples of structure, process and outcome indicators, and their associated standards, for use in
evaluating the fully established activities of a cancer palliative care programme
Structure
Policies and regulations include palliative care as a key component of national 21
cancer control
Funding and service delivery models established to support the provision of
cancer palliative care in all settings where patients receive care
Opioid prescribing laws and regulations for pain relief
List of essential medications for palliative care
Network of health-caregivers across the different levels of care
Network of community leaders and caregivers trained and motivated to
provide good quality palliative care services, including home-based care
Communities that own and support palliative care services
Educational courses that provide:
 Core knowledge and skills to practising health-care professionals
across all levels of care
 Expert knowledge and skills to a few selected health-care professionals
to lead palliative care services at the secondary and tertiary levels
 Undergraduate palliative care education for health-care professionals
(physicians, nurses, pharmacists, social workers)
Process
Number of advanced cancer patients receiving palliative care according to
established standards
Number and type of trained health-care professionals at the different levels
of care qualified to provide palliative care according to established standards
Proportion of advanced cancer patients who get early palliative care
according to established standards
Proportion of advanced cancer patients who get palliative care according to
20
Outcome
established standards
Proportion of advanced cancer patients receiving home-based care provided
by trained caregivers
Proportion of advanced cancer patients receiving home-based care who need
to be referred for specialised palliative care services at the secondary and
tertiary levels
Proportion of family caregivers who get psychosocial support through the
course of the disease, and through bereavement care, according to
established standards
Proportion of advanced cancer patients who get timely relief from pain and
other physical, psychosocial and spiritual problems
Proportion of caregivers of advanced cancer patients who get timely relief
from psychosocial and spiritual problems
21
2.7. Belgian Health Care Knowledge Centre (KCE)
The KCE is a Belgian federal institution aimed at advising policy-makers when deciding on health care
and health insurance through analysis and scientific studies. In the field of oncology, the KCE
produced several reports with regard to the development of recommendations of good clinical
practice and the assessment of health technologies. In the context of establishing a Belgian quality
system for oncology, the KCE set up three pilot studies to develop and assess indicators for the
evaluation of quality of care for colorectal, breast en testicular cancer (Reviewed in reference 16).
These quality indicators, selected on their reliability, relevance, interpretability and actionability, are
shown in Tabel 6.
TABLE 6. KCE QUALITY INDICATORS FOR RECTAL, BREAST AND TESTICULAR CANCER
INDICATOR
DOMAIN
INDICATOR
REF.
General
Rectal cancer Proportion of patients discussed at a MDT meeting
16
Indicators
Breast cancer Proportion of breast cancer women discussed at the MDT
meeting
Proportion of women with breast cancer who participate in
clinical trials
Testicular
Proportion of patients with testicular cancer discussed at
cancer
the MDT meeting
Proportion of patients with relapsing testicular cancer after
curative treatment that are included in a clinical trial
Rectal cancer Overall 5-year survival by stage
Disease-specific 5-year survival by stage
Proportion of patients with local recurrence
Breast cancer Overall 5-year survival by stage
Disease-specific 5-year survival by stage
Disease-free 5-year survival by stage
5-year local recurrence after curative surgery, by stage
Testicular
Overall 5-year survival by stage
cancer
Disease-specific 5-year survival by stage
Disease-free 5-year survival by stage
Diagnosis and
Rectal cancer Proportion of patients with a documented distance from
staging
the anal verge
Proportion of patients in whom a CT of the liver and RX or
CT of the thorax was performed before any treatment
Proportion of patients in whom a CEA was performed
before any treatment
Proportion of patients undergoing elective surgery that had
preoperative complete large bowel-imaging
Proportion of patients in whom a transrectal ultrasound
and pelvic CT and/or pelvic MRI was performed before any
treatment
Proportion of patients with cStage II-III that have a reported
22
Breast cancer
Testicular
cancer
Neoadjuvant
treatment
Rectal cancer
cCRM
Time between first histopathologic diagnosis and first
treatment
Proportion of women with class 3, 4 or 5 abnormal
mammograms having an assessment with a specialist
within 2 months of mammography
Proportion of women with class 3, 4 or 5 abnormal
mammograms who have at least one of the following
procedures within 2 months after communication of the
screening result: mammography, ultrasound, fine-needle
aspiration, or percutaneous biopsy
Proportion of newly diagnosed cstage I-III breast cancer
women who underwent two-view mammography or breast
sonography within 3 months prior to surgery
Proportion of women who received axillary
ultrasonography with fine needle aspiration cytology of the
axillary lymph nodes before any treatment
Proportion of women in whom human epidermal growth
factor receptor 2 status was assessed before any systemic
treatment
Proportion of women in whom a ER and PgR status
assessment were performed before any systemic treatment
Proportion of breast cancer women with cytological and/or
histological assessment before surgery
Proportion of sentinel lymph nodes biopsy in cN0 patients
without contraindications
Proportion of patients with testicular cancer undergoing
tumor marker assessment before any treatment
Proportion of patients with testicular cancer undergoing
contrast-enhanced computed tomography (CE-CT) or MRI
for primary staging
Proportion of cStage II-III patients that received a short
course of neoadjuvant pelvic RT
Proportion of cStage II-III patients that received a long
course of neoadjuvant pelvic RT
Proportion of cStage II-III patients that received
neoadjuvant chemoradiation with a regimen containing 5FU
Proportion of cStage II-III patients treated with neoadjuvant
5-FU based chemoradiation, that received a continuous
infusion of 5-FU
Proportion of cStage II-III patients treated with a long
course of preoperative pelvic RT or chemoradiation, that
completed this neoadjuvant treatment within the planned
23
Breast cancer
Surgery
Rectal cancer
Breast cancer
(Adjuvant)
treatment
Testicular
cancer
Rectal cancer
Breast cancer
timing
Proportion of cStage II-III patients treated with a long
course of preoperative pelvic RT or chemoradiation, that
was operated 6 to 8 weeks after completion of the
(chemo)radiation
Rate of acute grade 4 radio(chemo)therapy-related
complications
Proportion of operable cT2-T3 women who received
neoadjuvant systemic therapy
Proportion of R0 resections
Proportion of abdominoperineal resection and Hartmann’s
procedures
Proportion of patients with stoma 1 year after
sphinctersparing surgery
Rate of patients with major leakage of the anastomosis
after sphincter-sparing surgery
Inpatient or 30-day mortality
Rate of intra-operative rectal perforation
Proportion of breast cancer women who underwent an
axillary lymph node dissection after positive SNLB > 2 mm
Proportion of women with high-grade and/or palpable
and/or large DCIS of the breast who had negative margins
after surgery, whatever the surgical option (local wide
excision or mastectomy)
Proportion of cStage I and II women who undergo breast
conserving surgery/mastectomy
Proportion of women with breast cancer recurrence after
breast conserving surgery who are treated by a
mastectomy
Number of annually surgically treated patients with
testicular cancer per centre
Proportion of p-ypStage III patients with R0 resection that
received adjuvant chemotherapy
Proportion of pStage II-III patients with R0 resection that
received adjuvant radiotherapy or chemoradiotherapy
Proportion of p-ypStage II-III patients with R0 resection that
started adjuvant chemotherapy within 3 months after
surgical resection
Proportion of p-ypStage II-III patients with R0 resection
treated with adjuvant chemo(radio)therapy, that received
5-FU based chemotherapy
Rate of acute grade 4 radio- or chemotherapy-related
complications
Proportion of women with a breast cancer who are
24
Testicular
cancer
Palliative care
Rectal cancer
Follow-up
Rectal cancer
receiving intravenous chemotherapy for whom the planned
chemotherapy regimen (which includes, at a minimum:
drug[s] prescribed, dose, and duration) is documented prior
to the initiation, and at each administration of the
treatment regimen
Proportion of women receiving adjuvant systemic therapy
after breast surgery for invasive breast cancer
Proportion of women with hormone receptor positive
invasive breast cancer or DCIS who received adjuvant
endocrine treatment (Tamoxifen/AI)
Proportion of women with HER-2 positive, node positive or
high-risk node negative breast cancer (tumor size > 1 cm),
having a left ventricular ejection fraction of .50-55% who
received chemotherapy and Trastuzumab
Proportion of women treated by Trastuzumab in whom
cardiac function is monitored every 3 months
Proportion of women who received radiotherapy after
breast conserving surgery
Proportion of women who underwent a mastectomy and
having ≥ 4 positive nodes who received radiotherapy on
axilla following ALND
Proportion of women with HER-2 positive metastatic breast
cancer who received Trastuzumab with/without
nonanthracycline based chemotherapy or endocrine
therapy as first-line treatment
Proportion of metastatic breast cancer women who receive
systemic therapy as 1st and/or 2nd line treatment
Proportion of women with metastatic breast cancer and
lytic bone metastases who received biphosphonates
Radiation dose and field in patients with testicular cancer
treated with radiotherapy by stage
Proportion of patients with stage I non-seminoma treated
with active surveillance
Proportion of patients receiving CE-CT or MRI for residual
disease assessment at the end of systemic treatment
Degree and duration of active surveillance in patients with
stage I non-seminoma or seminoma
Rate of cStage IV patients receiving chemotherapy
Rate of acute grade 4 chemotherapy-related complications
in stage IV patients
Rate of curatively treated patients that received a total
colonoscopy within 1 year after resection
Rate of patients undergoing regular follow-up
Late grade 4 complications of radiotherapy or
25
Breast cancer
Histopathologic Rectal cancer
examination
Breast cancer
chemoradiation
Proportion of women who benefit from an annual
mammography after a history of breast cancer
Use of the pathology report sheet
Quality of total mesorectal excision assessed according to
Quirke and mentioned in the pathology report
Distal tumor-free margin mentioned in the pathology
report
Number of lymph nodes examined
(y)pCRM mentioned in mm in the pathology report
Tumor regression grade mentioned in the pathology report
(after neoadjuvant treatment)
Proportion of breast cancer resection pathology reports
that include the tumor size (macro-and microscopically
invasive and DCIS), the histologic type of the primary
tumor, the pT category (primary tumor), the pN category
(regional lymph nodes including numbers), the
lymphovascular invasion and the histologic grade
Proportion of women with invasive breast cancer
undergoing ALND and having 10 or more lymph nodes
removed
26
CONCLUSION
The list of quality indicators was screened to identify potential indicators for the evaluation of the
impact of the implementation of a specific action and/or measure of the Cancer Plan 2008-2010. As
shown in Table 7, the resulting selection of useful indicators was small and not representative of the
content of the actions and measures described in the Cancer Plan 2008-2010.
TABLE 7. SELECTION OF QUALITY INDICATORS FROM THE LITERATURE THAT ARE USEFUL FOR THE EVALUATION OF THE
CANCER PLAN 2008-2010
Percentage of the population who are smokers by age, sex and social class
Tobacco survey:
 prevalence of tobacco smokers among adults;
 tobacco smokers among 10-14 years old;
 ex-smokers
Pregnant women smoking
Tobacco cessation rates among smokers with low to severe addiction
Exposure to environmental tobacco smoke (ETS)
Breast screening participating rate
Rate (%) In situ (breast cancer screening)
Proportion of breast cancer patients who were discussed by a multidisciplinary team (MDT)
Invasive cervical cancer incidence rates
Five-year overall survival rates for cervical, breast and colorectal cancer
Mortality rates
Stage at diagnosis: percentage of cases with a metastatic test
Waiting times from diagnosis to definitive treatment
Proportion of patients discussed at a MDT meeting
Percentage of cancer patients participating in clinical trials
Provision of optimal treatment (combination of surgery, radiotherapy and chemotherapy if patient is
diagnose early at a localised stage)
Clinical use of innovative cancer drugs such as Herceptin (trastuzumab), Avastin (bevacizumab), Aromasin
(exemestane), Femara (letrozole), Arimidex (anastrozole), Evista (raloxifene), Erbitux (cetuximab),
Eloxatin (oxaliplatin), Camptosar (irinotecan) and Xeloda (capecitabine)
Setting up cancer-specific targets
Introducing a comprehensive national cancer control plan (NCCP)
Making additional funding available to achieve these targets
Assigning the lead person or organisation to oversee the implementation
Putting quality assurance mechanisms in place for cancer care
Coordinating care and developing networks for service delivery
Identifying the key milestones and timeframes
Monitoring the progress
Making someone responsible if targets are not met
National guidelines (screening, diagnosis, treatment)
Case management (MDT)
27
Accreditation of health professionals
Licensing of hospitals
TNEH
Public expenditure on cancer drugs
Computer tomography (CT) scanner units per million people and GDP
Positron emission tomography (PET) scanners per million people
Percentage of radiation systems in the population
Medical technologies: magnetic resonance imaging (MRI) units and CT scans
Oncologists per million people
Use of morphine in cancer patients
Percentage of patients receiving palliative radiotherapy
Policies and regulations include palliative care as a key component of national cancer control
Number and type of trained health-care professionals at the different levels of care qualified to provide
palliative care according to established standards
Educational level attained
Income by decile
Gini’s index
In order to assess the impact of the implementation of specific actions and measures included in the
Cancer Plan 2008-2010, a bottom-up approach was required. Based on the content of the Cancer
Plan 2008-2010 (document March 2008) objectives were identified as well as valid indicators that
could be used to evaluate these objectives. The process is described in ‘Evaluation of the Cancer Plan
2008-2010: identification of a methodology’. This new list of pragmatic indicators, obtained in a
deductive way, was then used to determine the impact of selected actions and measures on health
outcomes.
28
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