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EUROCHIP
Health Indicators for
Monitoring Cancer in Europe
Health Monitoring Program (HMP)
EUROPEAN COMMISSION
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
Www.istitutotumori.mi.it/project/eurochip/homepage.htm
EUROCHIP
GROUP OF SPECIALISTS on
PREVENTION
Amsterdam, 12th-13th December 2002
Chairperson: Dr Benedetto Terracini
INTRODUCTION
TO THE
MEETING
Dr. Julietta Bloch
AIMS OF THE MEETING
• Discussion on the complete list of the indicators
• An updated list of indicators for “prevention” domain
• Definition of eventual new indicators for environmental
and occupational risks
• A consensual classification of these indicators by priority
• Information on sources for indicators at high priority
• Discussion on validity and standardization of indicator at
high priority
CONSIDERATIONS
Participants have to consider that:
• indicators at high priority should be in a limited
number;
• indicators should be able to suggest actions to
reduce inequalities and to promote health;
• indicators should refer to the “prevention” domain
• indicators have been developed considering 3 axes:
1) the natural disease’s history (prevention, screening,
diagnosis, treatment, surveillance, end results)
2) indicator groups as suggested by the ECHI
HMP project (demographic and social-economic factors,
health status, determinant of health, health system)
3) cancer sites
INTRODUCTION
Several axis for indicators
DPSEEA
Exposure
Outcome
Action
OECD
Relevance (- PARP/Olav)
Analytical soundness
Measurability
Scale of application (national/subnational)
Availability (cost)
Census
Health surveys  statistical power
Ad hoc
Specificity (to cancer)
Robustness (validity, sensitivity)
Precision (standardization of methods
for measurement)
Comparability
What is environment?
Everything
Non genetic
Non social
behavioural
natural
Specific chemical, physical,
biological agents
EUROCHIP
Health Indicators for
Monitoring Cancer in Europe
A project of the
Health Monitoring Program (HMP)
EUROPEAN COMMISSION
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
Www.istitutotumori.mi.it/project/eurochip/homepage.htm
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, to
help the development of the future
European Health Information System
WHAT ABOUT THIS
PRESENTATION
• METHODS
• FIRST RESULTS
• FUTURE
A METHOD FOR THE DISCUSSION
EUROCHIP MAIN AXIS OF ANALYSIS
EUROCARE/EUROPREVAL
CAMON
OCCURENCE
RISK FACTORS
SURVIVAL
LIST
PRE-CLINICAL
ACTIVITY/
SCREENING
OF
CANCER CARE
PREVALENCE
CANCER
RECURRENCE
AND MORTALITY
CANCER
INDICATORS
DIAGNOSTIC &
THERAPEUTIC
PROCEDURES
CLINICAL
FOLLOW-UP
A METHOD FOR 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
A METHOD
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
RESULTS
130
CANCER SPECIALISTS ARE INVOLVED IN
EUROCHIP
17
INTERNATIONAL MEETINGS HELD IN A YEAR
15
ALL COUNTRIES OF THE EUROPEAN UNION ARE
PARTICIPATING IN THE PROJECT
RESULTS
PRELIMINARY LIST OF 158 INDICATORS
EUROCHIP MEETINGS
38 INDICATORS AT HIGH PRIORITY
RESULT: INDICATORS AT HIGH PRIORITY
PREVENTION
1. Tobacco consumption
2. Tobacco abstinence
3. Consumption of fruit and vegetable *
4. Consumption of alcohol *
5. Body Mass Index *
6. Exposure to asbestos
7. AIDS incidence *
8. Prevalence of hepatitis B/C *
EPIDEMIOLOGY AND CANCER REGISTRATION
9.
10.
11.
12.
13.
14.
15.
16.
17.
Coverage of cancer registration
Incidence rates *
Survival rates *
Prevalence proportion *
Mortality rates *
* Connected with other HMP projects
Stage at diagnosis
Person-years life lost due to cancer
Completeness of the registration (DCO and Incidence / mortality)
% of microscopically cases *
RESULTS: INDICATORS AT HIGH PRIORITY
SCREENING
18. Breast cancer screening coverage
19. Cervical cancer screening coverage
20. Colorectal cancer screening coverage
21. Organized screening process indicators
TREATMENT AND CLINICAL ASPECTS
22. Interval between diagnosis and first treatment
23. Radiation equipment
24. % of centres with at least 2 radiation equipments
25. CAT Equipments
26. Compliance with guidelines
27. Patients treated by surgery / chemotherapy / radiotherapy
28. Palliative care teams
RESULTS: INDICATORS AT HIGH PRIORITY
MACRO SOCIAL-ECONOMIC VARIABLES
29. Education level attained *
30. Average income *
31. Gini index *
32. Gross Domestic Product *
33. Total Social Expenditure *
34. Total National Expenditure on Health *
35. Anti-tobacco regulations
36. Public Expenditure on Health for cancer
37. Total Public Expenditure on Health *
38. Private/Non Profit Expenditure on Health for cancer
39. Age distribution of population in 2010-2020-2030 *
40. Lifetables *
* Connected with other HMP projects
GDP and life expectancy at birth
$PPP
Life expectancy at birth
Yrs
I) GDP< 15611
72.4
II) 15611>GDP<17538
76.7
III) GDP>17538
76.8
I, Estonia, Poland, Slovenia, Slovakia, and Spain;
II, UK, Finland, Holland, Sweden, Italy, and Austria;
III, Iceland, Denmark, France, Germany, and Switzerland
GDP and cancer incidence
$PPP
World-age-stand. incidence
rate per 100,000
I) GDP< 15611
II) 15611>GDP<17538
III) GDP>17538
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 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 and cancer prevalence
Cancer prevalence
$PPP
proportion per 100,000
I) GDP< 15611
II) 15611>GDP<17538
III) GDP>17538
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 and cancer mortality
World-age-stand. mortality
$PPP
rate per 100,000
I) GDP< 15611
II) 15611>GDP<17538
III) GDP>17538
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
EUROCHIP PROVIDES
• METHODS FOR DISCUSSING AND
PROVIDING ACCEPTED INDICATORS
• A LIST OF INDICATORS FOR CANCER
• A FUTURE BASE TO STUDY CANCER IN
EUROPE WITH THE AIM TO REDUCE
INEQUALITIES AND PROMOTE HEALTH
Www.istitutotumori.mi.it/project/eurochip/homepage.htm
THOROUGHNESS
OF THE
INDICATOR LIST
Dr. Andrea Micheli
LIST OF EUROCHIP HIGH PRIORITY INDICATORS
PREVENTION
EPIDEMIOLOGY AND CANCER REG.
Tobacco consumption
Tobacco abstinence
Exposure to asbestos
Coverage of cancer registration
Stage at diagnosis
Person-years life lost due to cancer
Completeness of the registration
SCREENING
Breast cancer screening coverage
Cervical cancer screening coverage
Colo-rectal cancer screening coverage
Organised screening process indicators
MACRO SOCIALECONOMIC VARIABLES
Anti-tobacco regulations
Indicators on Public Expendit.
on Health for cancer
Indicators on Private Expend.
on Health for cancer
TREATMENT AND CLINICAL ASP.
Interval between diagnosis
and first treatment
Patients treated by surgery /
chemotherapy / radiotherapy
Radiation equipment
% of centres with at least
2 radiation equipments
CAT equipment
Compliance with guidelines
Palliative care teams
FIRST DISCUSSION
Occupational exposure other than
asbestos (Update of CAREX)
UV light
HPV
Pesticides
ETS
Recommendation/Legislation
INDICATORS AT HIGH PRIORITY (1)
PREVENTION
1. Tobacco consumption
2. Tobacco abstinence
3. Consumption of fruit and vegetable *
4. Consumption of alcohol *
5. Body Mass Index *
6. Exposure to asbestos
7. AIDS incidence *
8. Prevalence of hepatitis B/C *
EPIDEMIOLOGY AND CANCER REGISTRATION
8.
9.
10.
11.
12.
13.
14.
15.
16.
Coverage of cancer registration
Incidence rates *
Survival rates *
Prevalence proportion *
Mortality rates *
* Connected with other HMP projects
Stage at diagnosis
Person-years life lost due to cancer
Completeness of the registration (DCO and Incidence / mortality)
% of microscopically cases *
INDICATORS AT HIGH PRIORITY (2)
SCREENING
17) Breast cancer screening coverage
18) Cervical cancer screening coverage
19) Colorectal cancer screening coverage
20) Organized screening process indicators
TREATMENT AND CLINICAL ASPECTS
21)
22)
23)
24)
25)
26)
27)
Interval between diagnosis and first treatment
Radiation equipment
% of centres with at least 2 radiation equipments
CAT Equipments
Compliance with guidelines
Patients treated by surgery / chemotherapy / radiotherapy
Palliative care teams
INDICATORS AT HIGH PRIORITY (3)
MACRO SOCIAL-ECONOMIC VARIABLES
28) Education level attained *
29) Average income *
30) Gini index *
31) Gross Domestic Product *
32) Total Social Expenditure *
33) Total National Expenditure on Health *
34) Anti-tobacco regulations
35) Public Expenditure on Health for cancer
36) Total Public Expenditure on Health *
37) Private/Non Profit Expenditure on Health for cancer
38) Age distribution of population in 2010-2020-2030 *
39) Lifetables *
* Connected with other HMP projects
PRIORITY
LEVELS
Dr. Benedetto Terracini
PRIORITY LEVELS
A
Direct indicator – Important – With or without any problem
B
Indirect indicator – Important – With or without any problem
C
Potentially useful but with presenting a great deal of problems
D
Very low priority – Irrelevant
DO YOU WANT SOMETHING ELSE
AT HIGH PRIORITY?
Lifestyle
Tobacco consumption
Tobacco abstinence
Consumption of fruit and vegetables *
Consumption of alcohol *
BMI *
Environment
Exposure to asbestos
PM10 (?)
Infection
Preval of Hepatitis B/C *
AIDS Incidence *
Macro economical indicator
5Mv.09a Public expenditure on cancer prevention against tobacco
5Mv.10a Private/Non profit exp. on cancer prevention
O
t
h
e
r
g
r
o
u
p
s
B1
B2
connected with other
HMP projects
C1
C2
connected with other
HMP projects
1.Tobacco sales
2.Tobacco price
1.Active vs sedentary occup
2.Physical fitness
3.Physical activity at work
4.Phys activ at leisure time
5.Oral contraceptive drug
6.Hormonal replacement
treatment drug
1.Radon expos in households
2.Exposure to PAH
1.Consumpt.of vegetable fibre
2.Consumption of meat
3.Cons. of processed meat
INDICATORS ON
TOBACCO
TOBACCO CONSUMPTION
Simple indicator
(only cigarettes)
CONTEXT
National survey &
Health For All DB
SOURCE
WHO suggests
caution in comparison
STANDARDIZATION
No problems with the
European survey
No indications
VARIABILITY
Relevant
No indications
VALIDITY
Under reporting
Complex indicator
(all type of smoking)
European survey
Advanced conclusion: We suggest an European survey
indipendently from the indicator choice
From HEALTH FOR ALL Database
TOBACCO ABSTINENCE
CONTEXT
SOURCE
STANDARDIZATION
VARIABILITY
VALIDITY
% past smokers who quitted tobacco
smoking by time since quitting
European survey
No problems with the European survey
Relevant
No problems
DISCUSSION ON
• Types of smoking to consider in the survey
• Periodicity of the survey
• Problem of children
• Under-reporting: could we assume the
uniformity of the under-reporting?
EXPOSURE TO
ASBESTOS
EXPOSURE TO ASBESTOS
% Employers in
naval dockyards
CONTEXT
Mortality trends for
mesothelioma
Difficult to find
SOURCE
WHO Mortality
Database
Problem of the
exposure time
STANDARDIZATION
No problems
No indications
VARIABILITY
Validation is really
difficult
VALIDITY
Exposure to asbestos is
concentrated in small areas
Misclassification
of cases
Advanced conclusion: We suggest to use the
mesothelioma mortality indicator
DISCUSSION ON
• Other eventual proxy for the indicator
• Misclassification of mesothelioma cases
First suggestion: Update CAREX Database
considering as indicator “Number of exposed
workers to carcinogenic”
NEW INDICATORS
DISCUSSION ON
• Indicators for environmental risk (PM10…)
• Indicators for occupational risk (Radon, PAH…)
• Indicators on infection
• Other indicators on lifestyle (diet, physical
activity…)
• Indicators on drugs
EUROPEAN COMMISSION
PUBLIC HEALTH
PROGRAMS
Dr. Andrea Micheli
PUBLIC HEALTH
IN EUROPE
• the European past and next strategy
FOCUS ON CANCER
• past/present in HMP: EUROCHIP and CAMON
• next: Working Party
Priority areas of
the public health programme
General health policy
Health
information
Health determinants
Health threats
By Dr. Tapani Piha
Bringing programmes together
-2002
Health monitoring
Injury
Health
Cancer
Pollution
Aids
information
Rare diseases
2003By Dr. Tapani Piha
Bringing programmes together
-2002
Health monitoring
Injury
Health
Cancer
Pollution
Aids
information
Rare diseases
2003By Dr. Tapani Piha
Public health programme
Implementation focus
• European added value
• Large scale (in content and geographical
coverage) multi-annual and multidisciplinary
• Leads to sustainable results and outputs
• Relevant and contributes to policy development
• Attention to the evaluation of the process and
results
By Dr. Tapani Piha
Stages in data processing
Stage 3
Data collection,
processing and storage
at EU level
Stage 4
Analysis, advice,
reporting, informing
and consulting
Stage 5
Mechanisms for
exchanging, promoting
and disseminating
results
Stage 2
Support to
data collection
at national level
Stage 1
Data definition
and
quality development
By Dr. Tapani Piha
FINAL
LIST OF INDICATORS
Lifestyle
1. Prev. of current tobacco smokers among adults
2. Prev. of tobacco smokers among 10-14
3. Prev. of ex-smokers
4. Consumption of fruit and vegetables *
5. Fast-food
6. Consumption of alcohol *
7. BMI *
8. Physical activity *
Environment
9. Prev. pop. exposed to ETS
10. PM10
11. Indoor exposure to radon
12. Awareness of risk associated to exposure to UV radiations
Occupational risk
13. Prev. of occupational exposure to carcinogens
14. Exposure to asbestos: Incidence and mortality trends
Medicaments
15. Hormonal Replacement Treatment Drug