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EUROCHIP-2 EUROCHIP-2 - The Action www.tumori.net/eurochip Public Health Program EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL.

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Presentation on theme: "EUROCHIP-2 EUROCHIP-2 - The Action www.tumori.net/eurochip Public Health Program EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL."— Presentation transcript:

1 EUROCHIP-2 EUROCHIP-2 - The Action Public Health Program EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL

2 EUROCHIP2: INEQUALITIES IN CANCER MANAGEMENT

3 The area of the disk is proportional to the Total National Health Expenditure ($ PPP) in the country $ PPP: Parity Purchasing Power per capita (US $) Sources: OECD 2002 for GDP and TNEH; EUROCARE-3 for survival Gross Domestic Product (1997) and 5-year- age- and cancer site- adjusted relative survival (women)

4 Relation between age standardised -prevalence (P), -incidence (I), and -relative survival for all malignant neoplasms in 17 European countries, 1992 (The area of the disk is proportional to the 5-year relative survival)

5 OUR INDICATIONS MUST REFER TO THE BEST STRATEGY FOR THE DIFFUSSION OF BEST PRACTICE

6 METHODS OF EUROCHIP-2 ACTIONS 1. Knowledge: finding data sources, improvement / standardisation of data collection 2. Choice: analyse data, compare data, find relations, find major deficiencies 3. Promotion: design, validate and finance initiatives to reduces cancer disparities These phases should be looked at as part of an iterative process

7 Steering Committee Working Team Operational work Panel of Experts Methodological Group Methodological aspects of the indicators GS: Groups of specialists a) Promotion of the action at national level or b) International domain level (prevention, cancer epidemiology, screeningcare&treatment,macro-indicators) GS GS care and treatment GS GSGS GS GS EUROCHIP : THE ORGANISATION Standardised methods for collecting, checking and validating the data proposed for each indicator Cancer network

8 THE PROCESS APPROACH (Eurochip-2 form) Module (columns) and profile (rows)

9 AIMS OF EUROCHIP-2 1.Extending the collaboration of networks on cancer (new participating countries) 2.Establishing multidisciplinary working groups in each country (through help of willing and determined people) 3.Analysing the behaviour of various indicators in relation to their utility as determinants of clinical outcomes, possibly leading to modifications (continuous consensus conference) 4.Promoting at least one important ACTION in each country (to improve the system of cancer information and to support the fight against cancer – i.e. reduce disparities) 5.Establishing/strengthening a health information system in co- operation with other chronic disease networks as for common risk factor or morbidity indicators

10 MAIN PRESENT GOAL OF THE EUROCHIP- 2 NETWORK Organisation of national groups involving cancer experts, institutes and associations in all countries Members of the national groups must believe in the project and have to be motivated in their work These groups have to be multidisciplinary groups Members of the National Groups have to identify specific problems at national levels and then make proposals on health planning These proposals have to reach the maximum consensus possible in the country

11 TASKS OF THE NATIONAL GROUPS To check the availability of the Eurochip indicators in own country (Eurochip Questionnaire) To promote data collection To use and analyse already available data To identify health system deficiencies at national level To propose actions against these deficiencies To reach the maximum consensus on actions

12 THE ROLES OF DOMAIN GROUPS THE ROLES OF DOMAIN GROUPS To test the present quality of EUROCHIP indicators To detect possible actions in their specific field To answer specific questions at national level To support actions related to their specific field EUROCHIP WORKING GROUP IS PREPARING THE INDICATOR/ACTION MATRIX

13 ACTIONS - e.g.: Poland Knowledge: Poland is involved in the EUROCARE studies Action: Application for funds in order to take part to Eurocare High Resolution Studies Choice: a) Poland has the lowest cancer survival in Europe b) Delay of cancer treatment and type of treatment used (Treatment Domain task: Standard Protocols for these Studies) Promotion Action: Health planning documents suggesting the delay of treatment and non-modern treatment as cause of the lowest cancer survival in Europe

14 ACTIONS - e.g. (1): Switzerland Knowledge: Surveys exist, yet with no questions on screening Action: Introducing questions on screening in the surveys Choice: data are available, yet no specific analysis is carried out Action:To promote analysis and publication of the data Promotion: Disparities in cancer information due to Canton health system Action: To promote the creation of a National Institute of Epidemiology

15 ACTIONS - e.g.(2): Switzerland Knowledge: There are no real data to evaluate cancer treatment, except for the Eurocare data in Geneva and Basel Action: To create a database analogous to Eurocare for all Swiss Cancer Registries Promotion: Disparities in fund and organisation Action: To guarantee the long-term work of all cancer registries

16 Computed Tomography Scanners and 5-year- age- and cancer site- adjusted relative survival (F)

17 EUROCHIP-2 POSSIBLE FUND USE The funds for partners have to be used only for personnel costs The possible various uses for these funds are: Organisation of the national group Involvement in the Eurochip pilot studies Collection of available data Analysis of data Creation of writings of health planning Connection with health planners and politicians

18 INDICATORS ON CARE & TREATMENT European benchmarking in cancer care Dr Ian Kunkler EUROCHIP-2 - The Action Public Health Program EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL PANEL OF EXPERTS’ Meeting – April 11 th,2005

19 Care and treatment list of approved indicators Definitions of datasets required Guidelines for modus operandi and timelines for national and regional european working groups Use of EUROCHIP resources for project deliverables (data collection and analysis) Next steps

20 EUROCHIP 2 – care and treatment parameters Provision of CT scanners Provision of megavoltage RT units Delays in diagnosis and treatment Compliance with best practice

21 CTS EQUIPMENT WHAT? Number of diagnostic CT (Computed Axial Tomography or computed tomography scanners) systems per population WHY? Level of availability of diagnostic facilities HOW? Health Ministry or Surveys

22 Computed Tomography Scanners – ITALY - MACROAREAS Source: Health for all - Italy Note: South Italy => Low survival

23 RADIATION EQUIPMENT RADIATION EQUIPMENTWHAT? Number of linear accelerators per population WHY? Availability of treatment facilities HOW? Health Ministry or Surveys

24 RADIATION EQUIPMENT and CTS EQUIPMENT PROCESS APPROACH PROCESS APPROACHKNOWLEDGE Identification of availability in European countries Comparison of equipment information collected in different countriesCHOICE Analysis of the European differences Finding relations with cancer outcomesACTION To promote acquisition of new equipments

25 Requirements for modern radiotherapy service linear accelerators per 10 6 pop’n 3-dimensional planning computer and multileaf collimator for 3D conformal RT and/or intensity modulated radiotherapy (IMRT) CT simulator Full complement of radiographers, physicists, clinical oncologists to allow waiting targets to be met Royal College of Radiologists, London,2004

26 How much radiotherapy is needed and provided ESTRO QUARTS PROJECT (QUAntification of Radiation Therapy Infrastructure and Staffing Needs

27 QUARTS project Aim : provide estimates of staffing and infrastructure requirements for RT in EU Transparent link between epidemiological data and indications for RT based on best available evidence 53% of patients with cancer have indication for radical/palliativeRT (Delaney et al,2003)

28 Linac throughput 450 treatment courses per year Australia Health Technology Advisory Committee,1996 Swedish audit 350 courses per year Throughput varies with complexity, number of fractions, tumour type and stage

29 National recommendations on linacs per 0.5 million population UK2.0 Spain2.5 France3.6 Czech Republic1.4 Bentzen (2004)

30 QUARTS – data for estimates of megavoltage RT units per countryBentzen et al Proportion of patients with given type of cancer Incidence of cancer types in country RT retreatment rates Machine throughput (no of courses of RT per linear accelerator per year)

31 Evidence based use of radiotherapy Division of cancer care and epidemiology, Kingston, Ontario (McKillop, IJRBOP,2002) Swedish Council of Technology in Health Care (Acta Oncol) Collaboration for Cancer Outcomes Research and Evaluation, NSW Au (Delaney et al)

32 Optimal use of radiotherapy Overall external beam RT needed in 53% all cancer patients (Delaney,2003) Some regions of UK only 22% offered RT (2002) Breast (83%) but clinical use 24%-71% Lung (76%) Prostate (60%) Rectum (61%) Gynae(31%)

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34 Radiotherapy: linac provision 2000 (Cottier,2004) No Linac Italy 198 Holland 73 England 159 France 275 Germany 363 % MLC 34%48%22%18%? Linac/ 10 6 pop Pop x

35 No of linacs needed per 10 6 pop’n to reproduce SBU pattern of RT usage Hungary 11.2 Denmark 5 Ireland 3.6

36 Limitations of QUARTS study Heavily reliant on Swedish and Australasian data Cross validation with other data sources valuable especially from central and southern Europe Data on stage needed since could differ between Australasian CCORE data and EU

37 EUROCHIP2-QUARTS collaboration Advantages: use of existing dataset and expertise on RT provision in 25 EU countries EUROCHIP2 could provide data on stage to crossvalidate QUARTS data based on SBU and CCORE

38 Measuring delay between diagnosis and first treatment Many ‘curative’ treatments involve multimodality treatment (surgery,systemic therapy,RT) Systemic therapy pre RT eg breast cancer may mask delays in access to RT Delays in access to RT best measured where no adjuvant chemo eg breast conserving therapy, early larynx cancer,early cervix ca

39 DELAY OF CANCER TREATMENT: CONTEXT Phases of disease history: Symptoms: not accurately 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 defined specifically site per site. As the date of first symptoms is not intrinsically defined as an event, the working group suggests to use the date of the first diagnosis as a reference. The indicator is the average time between date of diagnosis and date of first treatment The treatment group suggests specific definitions for 5 cancer sites: breast, colon, rectum, lung and prostate. To provide these indicators, Cancer Registries have to collect the dates of first treatment (either surgery, chemotherapy, radiotherapy or endocrine therapy)

40 DELAY OF CANCER CARE PROCESS APPROACH PROCESS APPROACHKNOWLEDGE Definition of disease history phases for 5 cancers: breast, colon, rectum, lung and prostate Identification of countries where pilot studies need be carried out Writing of pilot studies protocol Finding relations with cancer outcomesCHOICE Analysing data coming from pilot studiesACTION Promotion of the diffusion of the pilot studies Actions to reduce delay of cancer care

41 TODAY IN THE UK: CANCER PLAN IN UK : WAITING TIMES 1 monthMaximum 1 month wait from urgent GP referral to treatment guaranteed for children’s and testicular cancers and acute leukaemia 1 monthMaximum 1 month wait from diagnosis to treatment for breast cancer 1 monthMaximum 1 month wait from diagnosis to treatment for all cancers by monthsMaximum 2 months wait from urgent GP referral to treatment for breast cancer 2 monthsMaximum 2 months wait from urgent GP referral to treatment for all cancers by 2005 Cancer is the first priority for roll out of booked appointments By 2004 every patient diagnosed with cancer will benefit from pre- planned and pre-booked care

42 Clinical Standards Board for Scotland – breast cancer examples Minimum of 80% of patients with diagnosis within 2/52 of first clinic (including image-guided needle biopsy or excision biopsy) Therapeutic surgery: minimum of 70% within 3/52 of first clinic visit Minimum of 70% conservation rate of surgically treated small invasive cancers (<15mm path.diameter) excluding DCIS and multifocal disease Adjuvant RT: minimum of 70% within 4/52 of final operation/chemotherapy Adjuvant chemotherapy: minimum of 80% with 4/52 of final operation

43 COMPLIANCE WITH BEST ONCOLOGY PRACTICE PROCESS APPROACH PROCESS APPROACHKNOWLEDGE Update of the High Resolution Studies Protocol to collect data for these indicators Identification of cancer registries where organise HR Studies Collection of the dataCHOICE Analysing data coming from HR StudiesACTION Diffusion of the results

44 COMPLIANCE WITH BEST ONCOLOGY PRACTICE The indicator aims to reflect the compliance with best practices in oncology. BREAST  Proportion of patients receiving post-operative breast radiotherapy after breast conserving surgery  Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded) COLON  Proportion of patients with Dukes C (or TNM Stage 3) receiving adjuvant chemotherapy  Proportion of patients with Dukes B (or TNM Stage 2) not receiving adjuvant chemotherapy RECTUM  Proportion of patients receiving pre-operative radiotherapy LUNG  Proportion of patients with non small cell undergoing radical surgery  Proportion of patients undergoing staging with thoracic CT scanning CERVIX  Proportion of FIGO-stage III/IVreceiving combined chemo-radiotherapy  Proportion of patients with FIGO-stage “Ia2” and “Ib” undergoing hysterectomy with pelvic lymphadentectomy (WERTHEIM-MEIGS hysterectomy)

45 Guidelines For which parameters of best practice as defined by EUROCHIP2 is data routinely collected in each EU country for breast,colon,lung, rectum, lung, cervix at national/regional level? Is this data accessible to EUROCHIP (ethical considerations, confidentiality)? Proposals for data not collectable and/or not accessible Does EUROCHIP2 have necessary resources for data collation and analysis (eg how should per country funding best be used?)

46 PROPORTION OF PATIENTS TREATED WITH PALLIATIVE RADIOTHERAPY WHAT? Number of patients who have received palliative radiotherapy WHY? Quality of life for incurable cancer patients HOW? Survey on radiotherapy units

47 Requirements for modern radiotherapy service ‘Unfortunately there is not a single department in the UK that meets all these requirements’ Royal College of Radiologists,2004

48 Differences in palliative RT for bone metastases in W.Europe (Lievens et al,2000) Questionnaire survey of 565 RT centres 205 centres responded (36%) Most common RT schedule 30 Gy in 10 fractions largest centres used shorter fractionation and less complex treatments Level 1 evidence that single fractions as effective as multiple fractions

49 Lung cancer waiting times and tumour growth Prospective audit of 29 lung cancer patients awaiting radical (curative) radiotherapy Comparison of tumour size on diagnostic and RT planning scans 2 progressed so unfit for RT, 4 tumours became too large for radical RT 21% of patients became incurable Median time Ist hospital visit to starting RT= 94 days (range ) O’Rourke N Clin Oncol 2000;12:141-4

50 Conclusions Collaboration needed with ESTRO QUARTS project for RT equipment and palliative RT provision Engage the oncology community Use of high resolution studies Identification of: (i) provision of diagnostic CT scanners (ii) date of diagnosis and date of first treatment (iii) national/european audit data on compliance with evidence based guidelines

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52 Reimbursement for radiotherapy in Poland Until 1999 National Health system based on block budget (no fee for patient, nor for service) From1999: Fee for patient and fee for service. Curative 1000 –2300 E Palliative 500 E Brachytherapy 500 –1000 E

53 DECISIONS EUROCHIP-2 - The Action Public Health Program EUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL PANEL OF EXPERTS’ Meeting – April 11 th,2005

54 Clinical Standards Board for Scotland – breast cancer examples Minimum of 80% of patients with diagnosis within 2/52 of first clinic (including image-guided needle biopsy or excision biopsy) Therapeutic surgery: minimum of 70% within 3/52 of first clinic visit Minimum of 70% conservation rate of surgically treated small invasive cancers (<15mm path.diameter) excluding DCIS and multifocal disease Adjuvant RT: minimum of 70% within 4/52 of final operation/chemotherapy Adjuvant chemotherapy: minimum of 80% with 4/52 of final operation

55 HIGH RESOLUTION STUDIES (HR) vs EUROCHIP COULD WE USE BREAST HR FORMS TO COLLECT DELAY INDICATOR? Dates in Breast HR form are not sufficient Pilot studies in 3-4 Cancer Registries (CR) in order to verify if it is possible to have dates different from date of diagnosis today collected by CRs To enlarge the UK procedures to other countries: is it possible? First hospital clinic visit (first hospital contact) Date of positive mammography Date of first microscopical diagnosis (citology, biopsies) Date of first treatment (surgery, systemic therapy or radiotherapy ) – ALREADY PRESENT IN HR FORM PS Menu of data sources

56 HIGH RESOLUTION STUDIES (HR) vs EUROCHIP COULD WE USE COLON HR FORMS TO COLLECT DELAY INDICATOR? Pilot studies in 3-4 Cancer Registries (CR) in order to verify if it is possible to have dates different from date of diagnosis today collected by CRs Dates relevant to delay to collect: First hospital clinic visit (first hospital contact) Date of colonoscopy-sigmoidoscopy or barium enema Date of first microscopical diagnosis (citology, biopsies) Date of first treatment (surgery, systemic therapy or radiotherapy ) – ALREADY PRESENT IN HR FORM information on complete TNM information on elective or emergency surgery PS Menu of data sources: CR, HR, clinical notes, screening files, oncology-surgery-radiotherapy-pathology-laboratory-radiology department records, hospital or outpatient discharge, others to be specified ask to all EUROCHIP participants (by national groups)

57 COMPLIANCE WITH BEST ONCOLOGY PRACTICE The indicator aims to reflect the compliance with best practices in oncology. BREAST  Proportion of patients receiving post-operative breast radiotherapy after breast conserving surgery  Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded) COLON  Proportion of patients with Dukes C (or TNM Stage 3) receiving adjuvant chemotherapy  Proportion of patients with Dukes B (or TNM Stage 2) not receiving adjuvant chemotherapy RECTUM  Proportion of patients receiving pre-operative radiotherapy LUNG  Proportion of patients with non small cell undergoing radical surgery  Proportion of patients undergoing staging with thoracic CT scanning CERVIX  Proportion of FIGO-stage III/IVreceiving combined chemo-radiotherapy  Proportion of patients with FIGO-stage “Ia2” and “Ib” undergoing hysterectomy with pelvic lymphadentectomy (WERTHEIM-MEIGS hysterectomy)

58 TODAY IN UK: CANCER PLAN IN UK: CARE & TREATMENT Extension of guidance programmes to all cancers Establishment of specialist team Care of all cancer patients will be reviewed by specialist team Monitoring progress to achieve standards National cancer datasets Strenghtening cancer registries Improved information for patients New internet resources for patients Developping guidance for supportive care Extra subsidizing for hospices and specialist palliative care services


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