Medical Research Projects EUROCHIP-2 Cancer monitoring report in Romania

EUROCHIP Romania - Cancer monitoring report in Romania

Dr. Iuliana Apostol; Dr. Cornelia Nitipir
EUROCHIP-2, PE Romania
"Dr. Victor Babes" Foundation, Bucharest, Romania

The importance of the cancer control programs is stressed by two international leaders in the field: IARC - World Health Organization (WHO) and Cancer Prevention Control - Center for Disease Control (CDC). In 1995 WHO published the first document on "National Cancer Control Programs" and CDC has developed a model framework for Comprehensive Cancer Control. Cancer monitoring is nowadays a fundamental instrument of every national cancer control program. Its importance derives from the necessity to identify several evidence-based strategies and choose those that are feasible to implement, acceptable and relevant to the society, when planning a national cancer program.

In Romania, the following monitoring cancer programs are run :

  • The National Program for Public Health for Prevention and Control of Non-Communicable Diseases (NCD);
    • Prevention and Control in Oncology
  • EU Phare Project RO-2002/000-586.04.11.03 entitled "Improvement of NCD monitoring and evaluation capacity in the context pf health care sector reform in Romania" (2002-2004)
  • European Cancer Health Indicator Project - EUROCHIP-2, a EU project within the framework of the European Health Monitoring Programs (HMP)

The evaluation of the existing cancer monitoring system begins with data sources description. The principal data sources are: the Romanian Cancer Registry, Romanian health surveys (polls), the Romanian Ministry of Health Report/2004, EU Phare RO-2002/000-586.04.11.03 interim report and EUROCHIP questionnaire.

From these data sources we have verified the availability of cancer indicators in Romania, in relation with EUROCHIP indicator list.

1. Pr a - Prevention

  • Lyfestyle
    • 01 Consumption of fruit and vegetables *
    • 02 Consumption of alcohol *
    • 03 Body Mass Index distribution in the population *
    • 04 Physical activity *
    • 05 Tabacco survey * : prevalence of
      • a) tabacco smokers among adults
      • b) tabacco smokers among 10 - 14 years olds
      • c) ex-smokers
  • Environment & Occupational Risk
    • d) exposure to environmental tabacco smoke (ETS)
    • 06 Exposure to sun radiation
    • 07 PM 10 (particulate matter=10 um3) emissions
    • 08 Prevalence of occupational exposure to carcinogens
    • 10 Exposure to asbestos:mesothelioma incidence and mortality trends
  • Medicaments
    • 11 Prevalence of use of hormonal replacement drugs *

Notes :
a : Domain code;
* : Examined within other projects of the EU Health Monitoring Programmes (HMP);
bold : High priority indicators

2. Ep a - Epidemiology & Cancer Registration

  • 1 Population covered by high quality Cancer Registries
  • 2 Cancer incidence rates, trends and projections *
  • 3 Cancer relative survival rates, trends and projections *
  • 4 Cancer prevalence proportions, trends and projections *
  • 5 Cancer mortality rates, trends, projections and person-years of life lost due to cancer *
  • 6 Stage of diagnosis : percentage of
    • a) cases with early diagnosis
    • b) cases with a metastatic test

Notes :
a : Domain code;
* : Examined within other projects of the EU Health Monitoring Programmes (HMP);
bold : High priority indicators

3. Sc a - Screening

  • Screening examinations
    • 1 Precentage of women that have undergone a mammography (brest cancer)
    • 2 Percentage of women that have undergone a cervical cytology examination (cervical cancer)
    • 3 Percentage of persons that have undergone a colorectal cancer screening test
  • National evaluation in HMP of organized mass screening process indicators
    • 4a Organized screening coverage
    • 4b Screening recall rate
    • 4c Screening detection rate
    • 4d Screening localized cancers
    • 4e Screening positive predictive value
    • 4f Screening benign/malignant biopsy ratio
    • 4g Screening interval cancers
    • 4h Screening specificity

Notes :
a : Domain code;
bold : High priority indicators

4. Tr a - Treatment & Clinical Aspects

  • Health system delay
    • 1 Delay of cancer treatment (pilot studies)
  • Resources
    • 2 Percentage of radiation system in the population
    • 3 Percentage of diagnostic Coomputed Axial Tomographies (CTs) in the population
    • 4 Percentage of Positron Emission Tomographies (PETs) on population (for future)
    • 5 Percentage of magnetic resonances on population (for future)
  • Treatment
    • 6 Compliance with best oncology practice
  • Palliative care
    • 7 Use of morphine in cancer patients
    • 8 Percentage of patients receiving palliative radiotherapy

Notes :
a : Domain code;
bold : High priority indicators

5. Mv a - Macro-social and Economic Variables

  • Social indicators
    • 01 Educational level attained *
    • 02 Income by decile *
    • 03 Gini's index *
  • Macro economics indicators
    • 04 Gross domestic product *
    • 05 Total social expenditure *
    • 06 Total national expenditure on health
    • 07 Total public expenditure on health
    • 08 Anti-tabacco regulations
    • 09a Public expenditure for cancer prevention on anti-tabacco activity
    • 09b Total expenditure for population-based cancer registries
    • 09c Total expenditure on organized cancer screening programmes
    • 09d Public expenditure on cancer drugs *
    • 09e Public expenditure on cancer research
    • 09f Estimated cost for a cancer patient
  • Demographic indicators
    • 10 Age distribution in 2010, 2020 and 2030
    • 11 Life-table quantities *

Notes :
a : Domain code;
* : Examined within other projects of the EU Health Monitoring Programmes (HMP);
bold : High priority indicators

The following institutions are involved in cancer monitoring in Romania:

  • Institutions under the supervision of the Romanian Health Ministry:
    • Public institutions :
      • Center for Health Statistics and Medical Documentation (CSSDM)
      • Public Health Institution (ISP)
      • National Institute of Research and Development in Health (INCDS)
      • General Directions of Medical Insurance (DGAM)
      • Bucharest Oncologic Institute (IOB)
      • Cluj Oncologic Institute (INOC)
      • Regional oncology sections
    • Private institutions
      • Dr Victor Babes Foundation, Bucharest (FVB)
      • Center for Social Health Politics (CPSS)
      • SOFRECO
  • Institutions not under the supervision of the Romanian Health Ministry:
    • National Institute of Statistics (INS)

1. Field of cancer prevention

Indicators in this field are resulting from data derived from surveys (polls) with national impact.

Table 1 - indicators on cancer prevention

Consumption of fruit & vegetables Available; INS-yearly survey
Consumption of alcohol Available; INCDS-special survey (ESPAD)
Physical activity Not available
Body Mass Index Not available
Tabacco smokers adults Available; CPSS-suvey
Tabacco 10 - 14 years Not available
Prevalence of ex-smoker Available; CPSS-survey
Prevalence of ETS Not available
Exposure to sun radiation Not available
Prevalence of occupational exposure to carcinogens Available

Proposed actions :

  • 1.1 To ensure the continuation of existing surveys and to initiate new surveys in the areas not covered yet (e.g. survey regarding physical activity, BMI, ETS, exposure to sun radiation)
  • 1.2 To adapt the existing surveys to include the European indicators of cancer monitoring in order to have comparability (standardization) of data
  • 1.3 To improve the analysis and dissemination of data resulted from health surveys, which are necessary in planning new cancer programs
  • 1.4 To design some special programs that promote healthy lifestyle in children and young people - education about prevention in cancer and early detection

2. Field of cancer epidemiology

Indicators in this field are representative for cancer burden in each country. In Romania there exists a National Cancer Registry, whose reorganization is stipulated in the 2.2 Prevention and Control in Oncology and also in the EU Phare projects RO-2002/000-586.04.11.03. This registry is located at the Center for Health Statistics and Medical Documentation (CSSDM) and reorganized continuously; it functions in accordance with the European guidelines, as stated in the European Network Cancer Registry (ENCR).

Areas recently identified as need-improvement in this registry :

  • International Classification of Disease for Oncology (ICD-0) is not yet in use, making comparability between countries difficult
  • Geographical coding SIRUTA, for the uniqueness of towns and right registration of patients, is not in use
  • Personal identifier coding is not used, permitting some duplicate entries
  • There are still under-reported areas
  • There exists only a passive reporting system, with no follow-up and trace back procedures
  • The only information sources are the ONC1 form and the death certificate; there are no pathology reports and no data regarding stage at diagnosis
  • There exists only manually collected information and a poor analysis of data (lack of necessary software and hardware-IT infrastructure)
  • The cancer registrar profession does not exist and there are no specific training activities for people involved in collecting, processing, disseminating of data regarding cancer burden in Romania

Table 2 - indicators of epidemiology and cancer registration

Population covered by higy quality cancer registry Available
Cancer incidence rates Available
Cancer relative survival rates Not available
Cancer prevalence proportions Available
PYLL - Person-years Life Lost due to cancer Not available
Stage of diagnosis - % of cases with early diagnosis Not available
Stage of diagnosis - % of cases with a metastatic test Not available

Proposed actions :

  • 2.1 To adapt the database in accordance with ENCR and to standardize the data quality of cancer registry. The best intervention inside this action can be to set-up a cancer epidemiology department, inside CSSDM. This way we can assure the logistic support necessary to undertake the adaptations and permanent cancer monitoring. It is necessary to allocate enough human resources, create the cancer registrar profession, organize specific training for collecting, processing and dissemination of data and allocate financial resources for publishing a national report regularly
  • 2.2 To establish national incentives to stimulate the participation in European or international cancer programs and to organize exchange visits in order to limit the existing gaps regarding cancer epidemiology.
    e.g.1 Participation in : EUROCARE, study regarding survival rates and EUROPREVAIL, study regarding prevalence proportion.
    e.g.2 Application for ICRETT fellowships at Union Internationale Contre le Cancer (UICC), in order to participate on educational programmes regarding estimations in areas not covered by cancer registry

3. Field of cancer screening (early detection of cancer)

Opportunistic screening

In Romania it is mandatory to report the number of undertaken test screenings for breast, cervix, colorectal and prostate cancers, by the public medical institutions. In the private medical sector this reports are optional. These data are gathered by the Romanian Ministry of Health - General Direction of Medical Assistance, Mother and Child Assistance. The opportunistic screening is offered in primary health care settings, at the physician recommendation.

Organized screenings

In Romania, financial limitations impose the scarcity of organized screenings. Thus, the only organized screenings were made for cervical cancer, in limited areas without national estimates, between Jun 2002 - Jun 2004.

Table 3 - indicators of cancer screening

% of women that have a mammography Available, but with differences
% of women that have a cervical cytology Available, but with differences
% of persons that have a colo-rectal cancer test Available, but with differences
Organized screening coverage Available
Only for cervical cancer, the only organized screening program in Romania

Proposed actions

  • 3.1 To promote a health survey that evaluates opportunistic screening programs in Romania.
    Inside the action it will be necessary to design a study to analyze the relationship between screening programs and reduction of cancer site mortality (for which a systematic screening will have been implemented). Also, it will be necessary to provide the financial and human resources to complete this survey
  • 3.2 To initiate a sub-regional organized screening program and make studies on differences in the sub-regions involved

4. Field of cancer diagnostic and treatment

In Romania cancer treatment is offered inside the regional oncology sections from each Cantonal General Hospitals and affiliated ambulatory oncological services. There are two Oncological Institutes : Bucharest Oncology Institute (IOB) and Cluj Oncology Institute (INOC).

The medical oncologists first diagnose the majority of cancer patients and only a minority is diagnosed by GPs. Most of cancer patients are referred to one of the National Oncological Institute for confirmation of diagnosis and for treatment technical facilities.

In Romania, the cancer treatment is entirely compensated through national health insurance. From 2002, in Romania palliative care is recognized as a distinct medical field, there are physicians trained in palliative care and palliative treatment is offered to cancer patients at European standards. Palliative radiotherapy is available in both of the Oncological Institutes, but the indicator related to this treatment is not available.

Table 5 - indicators in diagnostic and cancer treatment

Delay of cancer treatment Not available
% of radiation system in the population Not available
No of linear accelerators/country is known but indicator is not calculated
% of diagnostic Computer Axial Tomographies (CTs) in the population Not available
Note: The number of CTs from public medical institutions are available at the Ministry of Health-Medical Equipment Direction; lack of data from private sector
Compliance with best oncology practice Not available
Percentage of patients treated with palliative radiotherapy Not available

There is no epidemiological data regarding the evaluation of cancer treatment in relation with EUROCHIP indicators and no indicators available in this field. There is a high priority to gather these data and to adapt the database of oncology institutions registries regarding the treatment.

5. Field of macroeconomics

In Romania there are strict anti-tobacco regulations since 2002 (law No 349/2002; Governmental Order No 13/2003; law No 275/2003)

  • Smoking in public places is illegal
  • Selling tobacco to people less than 18 years of age is prohibited
  • There are technical and hygiene rules in manufacturing, transport and selling of tobacco products

Data : September 2nd, 2005