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EUROCHIP
Health Indicators
for Monitoring Cancer
in Europe
Health Monitoring Program (HMP)
A Micheli a , P Baili a, A Quaglia b, E Paci c, A Ponti d, C Marinacci e, E Mugno a, C
Amati a, E Massimiliani a , N Bianchi a, A Cifalà a, H Lenz f, B Terracini g
(a) Unità di Epidemiologia, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano; (b) Struttura Epidemiologia Descrittiva, Istituto Nazionale Ricerca sul
Cancro, Genova; (c) CSPO Istituto Scientifico della Regione Toscana, Firenze (d) Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in
Piemonte (CPO-Piemonte), Torino (e) Servizio di Epidemiologia, ASL 5 Piemonte (f) Istituto Superiore di Sanità, Roma; (g) Università di Torino, Torino
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GDP and cancer incidence
World-age-stand. Incidence
$ PPP
I) GDP < 15611
II) 15611<GDP<17538
III) GDP > 17538
rate per 100,000
216.4
243.7
255.0
I, Estonia, Poland, Slovenia, Slovakia, and Spain;
II, UK, Finland, Holland, Sweden, Italy, and Austria;
III, Iceland, Denmark, France, Germany, and Switzerland
GDP, from OECD. Incidence, from “Cancer incidence in 5 continents”, EUROPREVAL
GDP and cancer mortality
World-age-stand. mortality
$ PPP
I) GDP < 15611
II) 15611<GDP<17538
III) GDP > 17538
rate per 100,000
140.5
128.3
133.6
I, Estonia, Poland, Slovenia, Slovakia, and Spain;
II, UK, Finland, Holland, Sweden, Italy, and Austria;
III, Iceland, Denmark, France, Germany, and Switzerland
GDP, from OECD. Mortality, from EUROCIM
GDP and cancer survival
5-year cancer relative survival
$ PPP
I) GDP < 15611
II) 15611<GDP<17538
III) GDP > 17538
%
33.4
44.1
45.2
I, Estonia, Poland, Slovenia, Slovakia, and Spain;
II, UK, Finland, Holland, Sweden, Italy, and Austria;
III, Iceland, Denmark, France, Germany, and Switzerland
GDP, from OECD. Survival, from EUROCARE-2
GDP and cancer prevalence
Cancer prevalence
$ PPP
I) GDP < 15611
II) 15611<GDP<17538
III) GDP > 17538
proportion per 100,000
1030.3
1405.5
1524.5
I, Estonia, Poland, Slovenia, Slovakia, and Spain;
II, UK, Finland, Holland, Sweden, Italy, and Austria;
III, Iceland, Denmark, France, Germany, and Switzerland
GDP, from OECD. Prevalence, from EUROPREVAL
EUROCHIP AIMS
AN INTECTUAL WORK INVOLVING CANCER EXPERTS OF EU
MEMBERS, CANCER NETWORKS, INSTITUTES AND ORGANISATIONS
To produce a list of health indicators which
describe cancer in Europe finalized:
a) to help the development of the European Health
Information System
b) to reduce inequalities and
c) to promote action in the fight against cancer
RESULTS
130
CANCER SPECIALISTS WERE INVOLVED
IN EUROCHIP
23 INTERNATIONAL MEETINGS WERE HELD
ALL COUNTRIES OF THE EUROPEAN UNION
PARTICIPATED IN THE PROJECT
A FORM TO
DESCRIBE
THE
INDICATORS
For each indicator
compile a FORM
we
 DESIRED INDICATOR:
all indicator characteristics we
wish to have
 METHODOLOGY:
operational definition,
possible sources and
methodological issues
 AVAILABILITY in
different countries
AXES OF CLASSIFICATION
1. The natural history of cancer
• Prevention
• Screening
• Diagnosis
• Treatment
• End results
2. ECHI classification
• Demographic and social-economic factors
• Health status
• Determinants of health
• Health system
3. Tumour sites
CANCER SITES (1)
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
2. 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
CANCER SITES (2)
• Major cancers
- Stomach
- Head and neck-larynx, oropharynx (specifying ICD-9
code)
- Melanoma
- Bladder
• Other cancers
- Kaposi
- Mesothelioma
- Testis
- Lymphomas
- Leukaemia
- All childhood (0-14) cancers
- Cervix
LIST OF THE INDICATORS
PRIORITIES
HIGH
MEDIUM
Prevention
7 (2)
4 (2)
Epidem. & CR
6 (2)
-
Screening
4 (4)
7 (7)
Treatment
5 (5)
3 (3)
Social-economic
variables
4 (2)
12 (4)
TOTAL
26 (15)
26 (15)
• Population covered by Cancer Registry
• Organized screening coverage
• Anti-tobacco regulations
• Prevalence of occupational exposure to carcinogens
• Exposure to sun radiation
• Percentage of women that have undergone a mammography
• Percentage of women that have undergone a cervical citology exam.
• Percentage of persons that have undergone a colo-rectal screening test
• Percentage of radiation systems on population
• Percentage of diagnostic CT (Computed Axial Tomography) on pop.
• Proportion of patients treated with palliative radiotherapy
• Estimated cost for a cancer patient
• Stage at diagnosis: % of cases with early diagnosis and with a
metastatic test
• Delay of cancer treatment: pilot studies
• Compliance with best oncology practice
SOURCES: CANCER REGISTRIES
• Population covered by cancer registries
• Cancer incidence rates, trends and projections
• Cancer survival rates, trends and projections
• Cancer prevalence prop., trends and project.
• Cancer mortality rates, trends, projections and
person-years life lost due to cancer
• Stage at diagnosis: percentage of cases with early
diagnosis and with a metastatic test
• Delay of cancer treatment: pilot studies
• Compliance with best oncology practice
POPULATION COVERED BY CANCER REGISTRIES
DEFINITION
Proportion of the national population
that is covered by general populationbased Cancer Registries present in the
“Cancer Incidence in 5 Continents”
CLASSIFICATION
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
1. STAGE AT DIAGNOSIS:
PERCENTAGE OF CASES WITH EARLY DIAGNOSIS
DEFINITION
Proportion of cases classified as
"localised" with the condensed-TNM
CONTEXT
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.
SOURCE
The sources are the Cancer Registries
routine registration statistics
2. STAGE AT DIAGNOSIS:
PERCENTAGE OF CASES WITH A METASTATIC TEST
DEFINITION
The indicator is the percentage of cancer
cases with presence or absence of a
detection test for metastasis
DETECTION TESTS
- Cervix: chest x-ray and pelvic imagine
- Colon and rectum: liver ultrasound or
CT and chest x-ray
- Prostate: bone-scan
- Lung: CT thorax
SOURCE
The sources are the Cancer Registries.
Specific studies on major cancer sites are
to be promoted
DELAY OF CANCER TREATMENT
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/her symptoms
to the Health System (general practitioner, hospital ...)
Diagnosis: date defined by CR rules
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 it will be used the date of the first diagnosis (or first medical
attendance for some sites) as the first date reference.
EUROCHIP suggests to organise pilot studies in order to study the
meaning of first diagnosis-first treatment interval for breast, colon,
rectum, lung and prostate cancers.
To define this indicator, Cancer Registries have to collect the dates
of first treatment (all treatments are to be considered: surgery,
chemotherapy, radiotherapy or endocrine therapies)
COMPLIANCE WITH BEST ONCOLOGY PRACTICE
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)
EUROCHIP group defined specific items for breast, colon, rectum,
cervical and lung cancers.
The sources should be the Cancer Registries.
PERSON-YEARS OF LIFE LOST DUE TO CANCER
DEFINITION
Years lost due to cancer using general
life expectancy as reference
l 1
 (l
a 0
FORMULA
d at Pa
a)
* 100000
pat Pn
where a=age, l=age limit, dat=number of deaths at
age a, pat=number of persons aged a in country i at
time t, Pa=number of persons aged a in the reference
population, Pn=total number of persons aged 0 to l-1
in the reference population
Potential years of life lost standardized rate due to cancer (Age<75)
(per 100,000 standard population). 1997
Piemonte
Valle d'Aosta
Liguria
Lombardia
Trentino Alto Adige
Veneto
Friuli Venezia Giulia
Emilia Romagna
Marche
Toscana
Umbria
Lazio
Campania
Abruzzo
Molise
Puglia
Basilicata
Calabria
Sicilia
Sardegna
Italia
M
2518
2924
2358
2787
2364
2525
2780
2346
2290
2379
2285
2614
2547
2155
2230
2097
2275
F
1627
1556
1579
1688
1506
1491
1996
1602
1449
1541
1640
1597
1550
1314
1748
1404
1354
1882
1262
2066
2474
1449
1401
2400
1535
EUROCHIP RESULTS
•AN EUROPEAN COHOMPRENSIVE LIST OF
INDICATORS FOR CANCER
•FUTURE:
1. TO STUDY CANCER IN EUROPE WITH THE AIM
TO DESCRIBE DIFFERENCES
2. TO ESTABLISH GROUPS AT NATIONAL LEVEL
(NETWORK & INSTITUTIONS & PERSONS) TO
PROMOTE HEALTH AND ACTIONS
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INDICATORS “AVAILABLE”
LOW COSTS
• Population covered by cancer registry
• Cancer incidence rates, trends and projections
• Cancer survival rates, trends and projections
• Cancer prevalence prop., trends and project.
• Cancer mortality rates, trends, projections and
person-years life lost due to cancer
• Gross Domestic Product (OECD)
• Total Public Expenditure on Health (OECD)
SOURCES “AVAILABLE”
LOW COSTS
• Anti-tobacco regulations
• Organized screening coverage
SOURCE: UPDATE OF DATABASES
MEDIUM COSTS
• Prevalence of occupational exposure to
carcinogens (CAREX)
SOURCE: SURVEYS
MEDIUM COSTS
• % of radiation equipments on population
• % of diagnostic CT (Computed Axial
Tomography) on population
• % of patients treated with palliative radiotherapy
• Estimated cost for a cancer patient
SOURCE: HEALTH SURVEYS
MEDIUM COSTS
• Consumption of fruit and vegetables (EFCOSUM)
• Consumption of alcohol (ECAS)
• Body Mass Index distribution (EHRM)
• Physical activity (EUPASS)
• Tobacco survey (EHRM)
• Exposure to sun radiation
• % of women that have undergone a mammography
• % of women that have undergone a cervical citology
examination
•% of persons that have undergone a colo-rectal cancer
screening test
SOURCE: CANCER REGISTRIES
HIGH COSTS
• Stage at diagnosis: percentage of early diagnosis
and of cases with a metastatic test
• Delay of cancer treatment: pilot studies
• Compliance with best oncology practice
THE ORGANISATION
Steering Committee
GS: Groups of specialists
Discussion of indicators
at national and domain
level
Working Team
Operational work
Standardised
methods for
collecting,
checking and
validating the
data proposed
for each
indicator
Panel of Experts
GS
Discussion &
organization at
national level
GS
GS
GS
GS
GS
Methodological Group
GS
Methodological aspects
of the indicators
LIST OF INDICATORS
PRELIMINARY LIST OF 158 INDICATORS
EUROCHIP MEETINGS
52 INDICATORS
26 AT HIGH PRIORITY:
15 PROPOSED BY EUROCHIP
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