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EUROCHIP
Health Indicators for
Monitoring Cancer in Europe
Health Monitoring Program (HMP)
EUROPEAN COMMISSION
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL
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EUROCHIP INTRODUCTION
AIM: To produce a list of health indicators which describe
cancer in Europe, to help the development of the future
European Health Information System
STEP 1 (Jan 2002 – Jul 2002) : To discuss a preliminary list at national
level, in all members of the European Union. The result was a
list of more than 100 indicators subdivided by priority level
STEP 2 (Sep 2002 – Dec 2002) : To discuss the indicators (of the list
produced at STEP 1) by different domain (prevention, epidemiology and
cancer registration, screening, treatment and clinical aspects, and macro
social-economic variables). To discuss methodological problems for
the indicators at high priority.
STEP 3 (Jan 2003 – May 2003) : Definition of the final list of indicators
subdivided by domain and by priority level.
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EUROCHIP
Comprehensive range of health indicators for cancer:
EUROCARE/EUROPREVAL
CAMON
OCCURENCE
SURVIVAL
RISK FACTORS
LIST
OF
CANCER CARE/
PREVALENCE
CANCER
RECURRENCE
AND MORTALITY
CANCER
INDICATORS
PRE-CLINICAL
ACTIVITY/
SCREENING
DIAGNOSTIC AND
THERAPEUTIC
PROCEDURES
CLINICAL
FOLLOW-UP
Standardised methods for collecting, checking and validating the data
will be proposed for each indicator
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STEPS
130
CANCER SPECIALISTS ARE INVOLVED IN EUROCHIP
23
INTERNATIONAL MEETINGS HELD
ALL COUNTRIES OF THE EUROPEAN UNION ARE
PARTICIPATING IN THE PROJECT
This step:
 Final meeting at which the final selection of indicators will be
drawn up
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RESULTS
For each indicator we compile a FORM subdivided in three sections:
 DESIRED INDICATOR: all indicator characteristics we wish to have
 METHODOLOGY: operational definition, possible sources and
methodological issues
 AVAILABILITY in different countries
LIST OF INDICATORS
PRELIMINARY LIST OF 158 INDICATORS
EUROCHIP MEETINGS
60 INDICATORS SUBDIVIDED BY DOMAIN
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EUROCHIP FINAL RESULTS
(AT THE END OF STEP 3)
For each indicator EUROCHIP will produce:
1. A DESCRIPTIVE
•
•
•
FORM
including:
Desired indicators characteristics (definition, use, caveat …)
Operational definition and indications on sources
Indications on availability in all EU member countries
2. A METHODOLOGICAL FORM
•
•
•
including:
Methodological aspects (standardisation, validity, variability)
Bibliography on the indicator
Suggestions to the European Commission
Www.istitutotumori.mi.it/project/eurochip/homepage.htm
FUTURE
 EUROCHIP 2
 National EUROCHIP groups
 Publications
PUBLICATIONS
• European Journal of Public Health: special number with the
abstracts of the EUPHA meeting (Dresden, Nov 2002)
• Cultural spanish review “Las Claras” : an article on the EUROCHIP
Murcia meeting will be published
• European Journal of Public Health: an article on EUROCHIP is
under review
NATIONAL OR INTERNATIONAL MEETINGS
Abstracts of various presentations or posters are under review for:
• NAACCR annual meeting: Honolulu (Jun 03)
• AIRT (Italian association CR) meeting: Biella (Apr 03)
• Reunion du groupe pour l'epidemiologie et l'enregistrement du
cancer dans le pays de langue latine: Cuba (May 03)
• “Sociedad Española de Epidemiología” meeting: Toledo (Oct 03)
PLAN OF THE PUBLICATIONS
The Steering Committee decided this plan of publications:
• 1 article with EUROCHIP introduction: EUROPEAN JOURNAL
OF CANCER or EUROPEAN JOURNAL OF PUBLIC HEALTH
• 1 article on methodological aspects: ?
• 1 article on treatment aspects: EUROPEAN JOURNAL OF
CANCER
• 1 article on prevention: EUROPEAN JOURNAL OF CANCER ON
PREVENTION
• 1 article on screening: EUROPEAN JOURNAL OF CANCER ON
PREVENTION
• 1 article on cancer registration and epidemiology: EUROPEAN
JOURNAL OF CANCER
Preparation: before summer
In press: October-November
AIMS OF THE MEETING
 Approval of the entire list with
relevant material
 Give a priority to the indicators:
to find 15-20 most important
indicators
 A look of the future
EUROCHIP PROJECT:
LIST OF INDICATORS
GOAL: PRIORITIES
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)
Other major cancers
- Stomach for monitoring the decreasing trends (ethnic
differences)
- Head and neck-larynx, oropharynx (specifying ICD-9 code)
for prevention and care. Treatment for organ preservation.
Melanoma for prevention (early diagnosis-stage migration)
- Bladder: for mortality
Other cancers
- Kaposi for sentinel
- Mesothelioma for sentinel
- Testis for rare cancer
- Lymphomas (H for health services and NH for trends) and
Leukaemia (for treatment)
- All (or just Leukaemia?) childhood (0-14) cancers (for
survival) rare cancer
- Cervix (for screening) We need information on incidence and
mortality (note: corpus uteri vs cervix misclassification)
BACKGROUND OF THE LIST
The final list is the result of various
discussions on the priorities of each indicator.
These priorities considered together:
1. added value of the indicator,
2. problems on the collection of the data,
3. problems on the comparability among
European countries, and
4. costs of the collection
INDICATORS: UNRESOLVED PROBLEMS (1)
1. Awareness of risk associated to exposure to UV
radiations: which question for the survey?
2. PM10 emissions: cut-off
3. Screening coverage indicators: only on
organized screening or also on opportunistic
screening? Which source?
INDICATORS: UNRESOLVED PROBLEMS (2)
3. Number of units with at least 2 Linear
Accelerators or with a single Lin Acc.
4. Patients treated by surgery, chemotherapy…:
which is the utility of this indicator after the
collection of the indicator “deviance from best
oncology practice”?
5. Palliative care: which indicator?
L
I
S
T
PREVENTION: 14 (4)
Lifestyle: 7 (0)
Environment & Occupational risk: 6 (4)
Medicaments: 1 (0)
EPIDEMIOLOGY AND CANCER REGISTRATION: 10 (5)
Cancer registration coverage: 1 (1)
Epidemiological measure: 7 (3)
Cancer registration quality: 2 (1)
SCREENING: 13 (13)
Screening coverage: 3 (3)
National evaluation of org. scr. process indicators: 10 (10)
TREATMENT AND CLINICAL ASPECTS: 10 (10)
Health system delay: 1 (1)
Resources: 3 (3)
Treatment: 5 (5)
Palliative care: 1 (1)
SOCIAL AND MACRO-ECONOMIC VARIABLES: 18 (8)
Social indicators: 3 (0)
Macro economic indicators: 13 (8)
Demographic indicators: 2 (0)
PR
7 hp (2)
4 mp (2)
EP
6 hp (2)
SC
4 hp (4)
7 mp (7)
TR
5 hp (5)
3 mp (3)
MV
5 hp (2)
11 mp (2)
27 hp (15)
25 mp (14)
LEGENDA OF NEXT SLIDES
- In “red”: indicators proposed by EUROCHIP
- In “black”: indicators proposed by other
projects or networks
- In “CAPITAL”: indicators at high priority
- In “small”: indicators at medium priority
INDICATORS ALREADY AVAILABLE LOW COSTS or NO NEW COSTS
• EXPOSURE TO ASBESTOS: MESOTHELIOMA INCIDENCE
AND MORTALITY TRENDS
• CANCER INCIDENCE RATE AND TREND
• CANCER SURVIVAL RATE AND TREND
• CANCER PREVALENCE PROPORTION AND TREND
• CANCER MORTALITY RATE AND TREND
• PERSON-YEARS LIFE LOST DUE TO CANCER
• POPULATION COVERED BY CRs IN EUROCIM DATABASE
• Percentage of cases confirmed microscopically
• Education level attained
• Average income and Gini’s index
• GROSS DOMESTIC PRODUCT
• TOTAL SOCIAL EXPENDITURE
• TOTAL NATIONAL EXPENDITURE ON HEALTH
• TOTAL PUBLIC EXPENDITURE ON HEALTH
• Age distribution in 2010-20-30
• Life table quantities
SOURCES ALREADY AVAILABLE LOW COSTS or NO NEW COSTS
ANTI-TOBACCO REGULATIONS
NATIONAL EVALUATION IN HMP OF THE ORGANIZED
SCREENING PROCESS INDICATORS
• SCREENING VOLUME
• SCREENING RECALL RATE
• SCREENING DETECTION RATE
• SCREENING LOCALIZED CANCERS
• SCREENING BENIGN/MALIGNANT BIOPSY RATIO
• SCREENING INTERVAL CANCERS
• SCREENING SENSITIVITY
• SCREENING SPECIFICITY
SOURCE: UPDATE OF DATABASES - MEDIUM COSTS
• PREVALENCE OF OCCUPATIONAL EXPOSURE TO CARCINOGENS
• PM10 EMISSIONS
SOURCE: HEALTH SURVEYS - MEDIUM COSTS
• Consumption of fruit and vegetables
• Consumption of alcohol
• Body Mass Index distribution in the population
• Physical activity
• PREVAL. OF CURRENT TOBACCO SMOKERS AMONG
ADULTS
• PREVALENCE OF TOBACCO SMOKERS AMONG 10-14
• PREVALENCE OF EX-SMOKERS
• Prevalence population exposed to environmental tobacco smoke (ETS)
• Awareness of risk associated to exposure to Ultra-Violet radiations
• Breast cancer screening coverage
• Cervical cancer screening coverage
• Colo-rectal cancer screening coverage
SOURCE: OTHER SURVEYS - MEDIUM COSTS
• % OF RADIATION EQUIPMENTS ON POPULATION
• % OF UNITS WITH AT LEAST 2 LINACS
• % OF CT (COMPUTED AXIAL TOMOGRAPHY) ON POP.
• PUBLIC EXPENDITURE FOR CANCER DRUGS
• Public expenditure for cancer prevention on anti-tobacco activity
• Public expenditure for organized mass screening programmes
• Private/Non profit expenditure on cancer screening
• Public expenditure for cancer research
• Private non profit expenditure for cancer research
• Public expenditure for population-based Cancer Registries
• Private/Non profit expenditure for cancer registration
• Prevalence of use of hormonal replacement treatment drugs
• Palliative care indicator
SOURCE: CANCER REGISTRIES - HIGH COSTS
• STAGE AT DIAGNOSIS: CASES RECORDED IN CRS AND
MEDICAL RECORDS
• Completeness of cancer registration
• DELAY OF CANCER TREATMENT
• DEVIANCE FROM BEST ONCOLOGY PRACTICE
• Patients treated by
Surgery
Chemotherapy
Radiotherapy
Endocrine therapy
SOURCE: OTHER - HIGH COSTS
• Indoor radon exposure
COSTS SOURCE
HIGH pr.
MEDIUM pr.
Ind. already Pr: 1 (1) Ep: 6 (2)
LOW
Ep: 1 (0) Mv: 5 (0)
Mv: 4 (0)
COSTS or available
NO NEW Sources already Sc: 10 (10) Mv: 1 (1)
available
COSTS
Update
MEDIUM Health survey
COSTS
Pr: 2 (2)
-
Pr: 5 (0)
Pr: 4 (1) Sc: 3 (3)
Other surveys Tr: 3 (3) Mv: 1 (0)
HIGH
COSTS
ALL
Pr: 1 (0) Tr: 1 (1)
Mv: 7 (7)
CRs
Ep: 1 (1) Tr: 2 (2)
Ep: 1 (1) Tr: 1 (1)
Other
-
Pr 1 (1)
Pr: 8 (3) Ep: 7 (3)
Sc: 10 (10) Tr: 5 (5)
Mv: 6 (1)
Pr: 6 (2) Ep: 2 (1)
Sc: 3 (3) Tr 2 (2)
Mv: 12 (7)
INTRODUCTION
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)
Other major cancers
- Stomach for monitoring the decreasing trends (ethnic
differences)
- Head and neck-larynx, oropharynx (specifying ICD-9 code)
for prevention and care. Treatment for organ preservation. For
quality of life
- Melanoma for prevention (early diagnosis-stage migration)
Other cancers
- Kaposi for sentinel
- Mesothelioma for sentinel
- Testis for rare cancer
- Lymphomas (H for health services and NH for trends) and
Leukaemia (for treatment)
- All (or just Leukaemia?) childhood (0-14) cancers (for
survival) rare cancer
- Cervix (for screening) We need information on incidence and
mortality (note: corpus uteri vs cervix misclassification)
INDICATORS
(at high priority)
EXPOSURE TO ASBESTOS:
MESOTHELIOMA INCIDENCE AND MORTALITY TRENDS
DEFINITION
Incidence/Mortality variations for
Pleureal cancer and/or Perithoneal
cancer and/or Mesothelioma by period
and by administrative unit
The recent trends of mesothelioma or pleural and perithoneal cancers
mortality and incidence (last 3-5 years) can be real proxies of the
exposure to asbestos in the past.
They indicate either increasing, decreasing or even stable rates, thus
indicating a different phase of the asbestos epidemic.
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
a)
d at Pa
* 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
POPULATION COVERED BY CANCER REGISTRIES
PRESENT IN EUROCIM DATABASE
DEFINITION
Proportion of the national population
that is covered by general populationbased Cancer Registries present in the
EUROCIM database in a given period
(year)
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
NATIONAL EVALUATION IN HMP
OF THE ORGANIZED SCREENING PROCESS INDICATORS
The “screening group” underlined the importance to realise in HMP a national
evaluations of the process indicators of the organised screening programmes activity.
The group individuated the information necessary for this national evaluation:
Breast and colo-rectal cancer
Extension
=>
Availability of the programmes in the pop. and coverage
Acceptance
=>
Participation
Specificity
=>
Recalled, benign operations (open surgical procedures)
Sensitivity
=>
Detected by stage
Cervical cancer
Extension
=>
Availability of the programmes in the pop. and coverage
Acceptance
=>
Participation
Specificity
=>
Recalled (anything no negative)
Sensitivity
=>
Detected by CIN (histology) and invasive by stage
ANTI-TOBACCO REGULATIONS
The indicator refers to the description of the anti-tobacco regulation.
It is a multiple-indicator indicating presence or absence (Y/N) of a set of
specific laws on anti-tobacco regulation. These laws should refer to:
• restrictions in public places
• prohibition in hospitals
• prohibition at school (or universities)
• prohibition in public transport vehicles
• on-pack warnings
• indications on nicotine on pack
• limits on tar content
• employeees protection law (ETS)
• prohibition of Tv and radio advertising
• flight smoke prohibition in national airline
• sales to children/teenagers
• tobacco smoke labeled as a carcinogen
SOURCE: Corrao MA et al. Tobacco Control Country Profiles. American
Cancer Society, Atlanta, GA (2000)
PREVALENCE OF OCCUPATIONAL EXPOSURE TO CARCINOGENS
DEFINITION
Current prevalence of occupational
exposure to a given carcinogen
(recognized by the “International
Agency for Research on Cancer” in
the classifications 1, 2A and 2B)
EUROCHIP suggest to update and expand the present CAREX database.
This database, subsidized by the “Europe Against Cancer” Programme,
estimated the occupational exposure in all European countries by agent and
by industries for the period 1990-93.
Updating the already available database with the same methodology we
could also study if in the country the occupational exposure to carcinogens is
changed in this 10 years
PM10 (PARTICULATE MATTER <= 10µ3) EMISSIONS *
DEFINITION
Percentage of population living in
areas with a PM10 daily average
concentration above ? microgrammes
per air cubic metre
“Percentage of population living in urban areas with a PM10 daily
average above 50 microgrammes per air cubic metre” is an indicator
proposed in Europe by the group “Environmental health indicators
for the WHO Europe”. This group already provided a
methodological definition of the indicator and also considers it as a
realistic goal in the next future.
This indicator is the same proposed by EUROCHIP (we had not
proposed any limit value, as yet) so we recommends the EC to
include in the European Database also this indicator of the WHO
group. The only doubt is the value of 50 microgrammes per air cubic
metre because the EU directive indicates a lower value
INDICATORS ON TOBACCO *
• Prevalence of current tobacco smokers among adults
• Prevalence of tobacco smokers among 10-14
• Prevalence of ex-smokers
• Prevalence of exposure to environmental tobacco
smoke (ETS)
The project EHRM (European Health Risk Monitoring) proposed
the same indicators of EUROCHIP.
INDICATORS ON RESOURCES
RADIATION EQ.
Number of linear accelerators per
1 000 000 population
CT
Number of CT (Computed Axial
Tomography or computed tomography
scanners) equipments per 1 000 000
population
OTHER
Number of units with at least 2 Linear
Accelerator radiation equipments per
1 000 000 population OR Number of
units with a single Linear Accelerator
SOURCE
Survey on health structures and services.
The resource have to be working on 31st
December of the year prior to the survey
STAGE AT DIAGNOSIS: CLARIFICATIONS
We need to have this information:
STAGE AT DIAGNOSIS:
PERCENT OF CASES RECORDED IN CANCER REGISTRIES
DEFINITION
Proportion of cases classified with the
TNM value or, in absence, with
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
and exactly their routinary activity of
registration
STAGE AT DIAGNOSIS:
PERCENT OF CASES RECORDED IN MEDICAL RECORDS
DEFINITION
Percentage of cancer cases registered by
the clinician with the information of the
presence or absence of a detection tests
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
- Breast: different per stage
- T1-T2: chest x-ray
- T3-T4 or N+: bone-scan and liver ultrasound
SOURCE
The sources are the Cancer Registries
performing specific studies for major
cancer sites
DELAY OF CANCER TREATMENT: CONTEXT
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 symptoms to the
Health System (general practitioner, hospital ...)
Diagnosis: date defined specifically site per site
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 we suggest to use the date of the first diagnosis (or first medical
attendance for some sites) as a reference.
The treatment group suggests specifically definitions for the dates of first
diagnosis (or first medical attendance) and of first treatment for 5 cancer sites:
breast, colon, rectum, lung and prostate.
The Methodological Group suggests to study only breast, colon and rectum
for the high percentage of patients non-treated.
To define these indicators, the Cancer Registries have to collect the dates of
first treatment (and exactly on surgery, chemotherapy, radiotherapy or
endocrine therapy)
DELAY OF CANCER TREATMENT:
DEFINITION OF THE DATES
DATE
BREAST
1st medical
attendance
1st FNA
or
st
1 histolog.
confirm.
st
1 Surgical
resection or
1st neo-adj.
therapy
COLON
RECTUM
1st medical 1st medical
referral to a referral to a
specialist
specialist
LUNG
PROSTATE
1st histolog.
1st
or
histological
1st diagnosis
st
1 cytolog.
confirm.
confirm.
1st radical
1st surgical 1st surgical 1st surgical prostatect.
Surgery
resection
resection
resection
or 1st other
surgery
1st radical
1st curative radiotherapy
st
st
1 adjuvant
1 adjuvant
Radiotherapy
radiotherapy (external
radiotherapy
radiotherapy
treatment beam and/or
brachyther.)
st
1
1st adjuvant
chemother.
Chemother.
chemother.
treatment
st
1 Adjuvant
1st endocrine
Other
endocrine
therapy
therapy
therapy
DELAY OF CANCER TREATMENT : COMMENTS
Isabel Izarzugaza (Basque Country Cancer Registry)
The data for the delay of cancer treatment indicator could be collected
periodically for breast and colorectum. In a different period for prostate, in a
different period for some other tumour. For example during 1 year every 3
years breast and colorectum, the following year (everey 3 years) for prostate
and so on.
Risto Sankila (Cancer Registry of Finland
Why do we collect data, e.g. on delay of care, when in some parts of the
expanding EU there are no resources for proper diagnostics!
Who will utilise the information on 'Interval between first diagnosis and first
treatment' on the EU level, if the data are only collected from a (biased?)
sample of cancer clinics?
(To be continued…)
DELAY OF CANCER TREATMENT : COMMENTS
Torgil Moller (Swedish Cancer registry)
I think this is a very difficult item if you wish to study the time from symptom
to diagnosis and diagnosis to treatment. The date of start of symptom is often
very vague and undefined, maybe preceeded by irrelevant symptoms and thus
a matter of great subjectivity. I would like to suggest date of first contact with
health care system leading to the diagnosis in question as the starting point.
This is of course also a difficult item to collect, and necessitates maybe visits
to primary health care centres and GPs, but in any case it is a date that could
be defined.
The next problem relates to date of diagnosis. If we are studying delay in the
system, the date of histological confirmation based on surgical specimen
would in many cases result in a negative delay between date of diagnosis and
date of start of treatment. Thus, it is important to accept for example a positive
mammography plus cytology as the date of diagnosis, or clinical investigation
where no histological confirmation can be obtained, for example melanoma of
the eye or tumour of the brain stem. If this problem can be solved, then this
indicator might be of value. However, it could never be based on a routine
data collection but must be collected now and then within well defined
projects.
DEVIANCE FROM BEST ONCOLOGY PRACTICE: CONTEXT
The indicator is aimed to reflect the deviance to best
practice in oncology. It implies the existence of specific
professional guidelines and express something related to the
attitude to comply with guidelines rather best practice. To
give an indication on the patients treated according to the
guidelines, we need to collapse the guidelines themselves
into a few simple items. As guidelines usually refer to cases
that can be potentially cured, the indicator should refer to
patients potentially eligible for treatment according to
guidelines.
An examination of the “deviation” from guidelines is usually
more robust than a look at their “adherence”. The medical
attitude in following guidelines may vary considerably and
thus, is very difficult to classify. Defining the nonadherence is easier and more robust.
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)
DEVIANCE FROM BEST ONCOLOGY PRACTICE: CASES
BREAST
 Proportion of patients receiving post-operative breast radiotherapy after breast
conserving surgery (by age)
 Proportion of patients with pathological or clinical tumour site 3cm or less receiving
conserving surgery (by age)
COLON
 Proportion of patients with Dukes C receiving adjuvant chemotherapy
RECTUM
 Proportion of patients receiving pre-operative radiotherapy
PROSTATE
 Proportion of patients receiving radical prostatectomy (by age)
 Prop. of patients receiving radical radiotherapy by external beam or brachytherapy
LUNG
 Proportion of patients with non small cell undergoing radical surgery
 Proportion of patients undergoing staging with thoracic CT scanning
CERVIX
 Prop. of patients with FIGO-stage III/IV in cervix cancer receiving
chemoradiotherapy (by age)
 Prop. of patients undergoing WERTHEIM-MEIGS hystorectomy by FIGO-stage
(including insitu) (by age)
DEVIANCE FROM BEST ONCOLOGY PRACTICE: COMMENTS
Isabel Garau (Mallorca Cancer Registry)
Guidelines on diagnostic procedures may vary from country to country and
even for the areas covered by the cancer registries, but, when defined, (and I
think that is possible to define guidelines on this point) I think that cancer
registries could be able to collect these information.
But define guidelines for treatment into a simple way could be very difficult
(specially for the most interesting tumours) and, even if defined, I'm not sure
that cancer registries would be able to collect this information. I propose a
reflection and, if necessary, a pilot study on this indicator.
Torgil Moller (Swedish Cancer registry)
Indicator “Deviance from best oncology practice” also needs a lot of
definition and could maybe only be applied in certain situations where there is
a common agreement on the treatment method, such as breast conserving
surgery, preoperative radiotherapy in rectal carcinoma, etc. This indicator
must also be collected only within well defined projects, but could be of great
importance
INDICATORS
(at medium priority)
CONSUMPTION OF FRUIT & VEGETABLES *
Distribution of the population by daily
DEFINITION
portion of all fruits and vegetables
(excluding potato)
EFCOSUM (European Food Consumption Survey Method) underlined :
 DAFNE is the only database providing comparable data (household)
 EPIC develops methods to collect data focused on cancer and adults
Common guidelines are necessary in order to have comparable data
Data can be made comparable at the “raw edible” ingredient level
t is really important have comparable data on vegetables (potatoes
excluded), fruits (fruit juices excluded), bread, fish (stellfish included),
some nutrients (saturated fatty acids, total fat, ethanol) and some biomarkers
(folate, vitamin D, iron, iodine, sodium)
EUROCHIP is aware of the difficulties to have comparable data on dietary
habits but also of the real importance to have this information as the
consumption of fruit & vegetables is a major dietary protective factor for
cancer. For this reason EUROCHIP recommends the carrying on of projects
like EFCOSUM, DAFNE and EPIC.
CONSUMPTION OF ALCOHOL *
DEFINITION
Pure alcohol daily consumption
ECAS (European Comparative Alcohol Study) underlined:
 Total alcohol consumption per capita by beverage categories is an
important indicator for following developments in the EU public health
EU should prepare an authoritative report on tot. alcohol cons.
according to beverage categories and off- and on-premises sales
EU should also prepare a report on how basic figures for alcohol cons.
are and have been collected in different studies and how units used for
estimating individual consumption have been converted into litres
The EU should carry out such surveys on a regular basis in order to
monitor developments in drinking habits
EUROCHIP agreed with the ECAS recommendations to the EU and
underlines the importance to have a common European guideline in
order to have comparable data
BODY MASS INDEX DISTRIBUTION IN THE POPULATION *
Percentage of obese and overweight
population by BMI (Body Mass Index)
DEFINITION
BMI values:
25-30 Kg/m2: Overweight
30 + Kg/m2: Obesity
The project EHRM (European Health Risk Monitoring)
underlined the importance to have information on BMI in the EU.
It proposes the same indicator proposed by EUROCHIP.
PHYSICAL ACTIVITY *
Proportion of people carrying out
physical activity (moderate and
DEFINITION
strenuous activities) by number of
hours per working days or holidays
EUPASS (European Physical Activity Surveillance System)
recommended an European survey on physical activity (IPAQ)
including various questions.
The EUROCHIP indicator refers to the question A2 in the IPAQ:
A2. How much time on average do you spend per day (24 hours) on:
(Round up time to full or half hours – Like 0,5 Hrs. This concerns only physical activities or efforts. Please try to distribute all 24 hours over the 5 categories)
Mon-Fri
Sat-Sun
Sleeping, resting
__ __, __h
__ __, __h
Sitting
__ __, __h
__ __, __h
(like at the office, in the car, watching television, eating, reading)
Light activities
__ __, __h
__ __, __h
(like cooking, walking at low pace, shopping, tiding up the room, body care, selling)
Moderate activities
__ __, __h
__ __, __h
(like jogging, renovating, cleaning, construction work)
Strenuous activities
__ __, __h
__ __, __h
(like carrying heavy weights, strenuous gardening, chopping wood, competitive sport, ball games)
Total
24,0h
24,0h
AWARENESS OF RISK ASSOCIATED TO EXPOSURE TO UV RADIATIONS
DEFINITION
Proportion of persons reporting to be
aware (or not aware) with the UV
radiation and reporting to behave (or
not to behave) consistently
RATIONALE
Skin cancer incidences are increasing.
Exposure of UV radiations is the
major cause of skin cancers and it is a
behavioural trait. Awareness is the
only control measure
SOURCE
Health survey
From EHRM (European Health Risk Monitoring) project leader:
Concerning the indicator of ultraviolet raditions, are you proposing a
questionnaire item for collecting the information? I do not know if there
are validated questions which could be used.
PREVALENCE OF USE OF
HORMONAL REPLACEMENT TREATMENT DRUGS
DEFINITION
Hormonal Replacement Treatment
drug use in the female population from
50 to 69
The indicator refers to the number of prescriptions HRT in women
(indicator proposed by the pharmaceutical HMP project)
SCREENING COVERAGE INDICATORS
CONTEXT
It considers the effects of both organized and
opportunistic screenings
BREAST
Percentage of women aged between 40-49, 5069 and 70-74 examined by mammography in
the recommended interval
CERVIX
Percentage of women aged 20-29, 30-59 and
60+ examined by citology in the last 3-5 years
COLO-RECTAL
Percentage of persons aged 50-74 who have
had a fecal occult-blood test in the last 2 years
SOURCE
Organized screening programme databases for
countries with national programmes. In this
case we need the information on the frequency
of mammography examinations for females
who did not comply to participate to the
screening. For the other countries data should
be collected by survey and we need also
information from regional programmes
INDICATORS ON PALLIATIVE CARE
INDICATOR 1
Use of morphine units per cancer
patients
INDICATOR 2
Beds in palliative units in specialist
level and in primary care level
INDICATOR 3
Number of patients who have got
palliative radiotherapy or fractions of
radiotherapy as palliative purpose
INDICATORS ON PUBLIC/PRIVATE EXPENDIT. FOR CANCER
PREVENTION
Public expenditure for cancer prevention on
anti-tobacco activity (campaigns, initiatives,
facilities and so on against tobacco)
CR
Public and Private/Non profit expenditure
devoted to support population-based cancer
registration (SOURCE: question to CR)
SCREENING
Public and Private/Non profit expendit. for
cancer organized mass screening programs
by site (SOURCE: question to EBCN)
RESEARCH
SOURCE: survey
Public expenditure for cancer clinical trials
not supported by pharmaceutical companies,
fundamental research and contributions
from International Organisations
Private non profit expenditure for cancer
research regarding charity organizations
(specialized in cancer) reviewing reasearch
COMPLETENESS OF CANCER REGISTRATION
Completeness measure proposed in:
DEFINITION
Bullard J, Coleman MP, Robinson D, LUTZ JM,
Bell J, Peto J. Completeness of cancer registration:
a new method for routine use. British Journal of
cancer (2000) 82(5), 1111-1116
FORMULA
n
C( t )  1  s( tn )u( tn )   {[ s( ti
i 0
)  s( ti 1 )][ 1  m( ti )] u( ti )}
where
s(ti) = probability that a cancer patient is still surviving at time ti after diagnosis,
m(ti)= probability that the death certificate of a patient who dies in the time
interval (ti, ti+1 ) after diagnosis includes a mention of cancer
u(ti)= probability that a patient surviving until time ti) after diagnosis is still
unregistered
PATIENTS TREATED BY SURGERY, CHEMOTHERAPY ...
CONTEXT
Percentage of patients treated with surgery,
chemotherapy and radiotherapy.
SOURCE
The sources should be the Cancer
Registries. We suggest specific studies on
sample of cases in order to collect
information on therapy and stage, such as
the EUROCARE High Resolution Studies
It is not clear what the indicator would like to present.
It should be interpreted generally as “frequency of a specific treatment”.
It is not clear the rationale and the added value of the indicator: if we have a
good indicator on deviance from best oncology practice this indicator should
became redondant
INDOOR RADON EXPOSURE
DEFINITION
Percentage of people living in houses
with radon gas concentration above
200Bq/m3
The source will be national ad hoc surveys.
In the 90s Each European country organized a survey to know the
radon levels in dwellings in their territory. One of the results was the
percentage of dwellings with a radon level over 200Bq/m3
Bibliography
Bochicchio F et al. Radon in indoor air. Luxembourg, Office for Official
Publications of the European Communities, 1995 (European
Collaborative Action: Indoor air quality and its impact on man, No. 15)