1. 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

2. GROUP OF SPECIALISTS on PREVENTION Amsterdam, 12th-13th December 2002 EUROCHIP Chairperson: Dr Benedetto Terracini

3. INTRODUCTION TO THE MEETING Dr. Julietta Bloch

4. 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

5. 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

6. Several axis for indicators DPSEEA Exposure Outcome Action OECD Relevance (-  PARP/Olav) Analytical soundness Measurability Scale of application (national/subnational)INTRODUCTION

7. Availability (cost) Census Health surveys  statistical power Ad hoc Specificity (to cancer) Robustness (validity, sensitivity) Precision (standardization of methods for measurement) Comparability

8. What is environment? Everything Non genetic Non socialbehaviouralnatural Specific chemical, physical, biological agents

9. 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

10. 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

11. WHAT ABOUT THIS PRESENTATION METHODS METHODS FIRST RESULTS FIRST RESULTS FUTURE FUTURE

12. LISTOFCANCER INDICATORS INDICATORS RISK FACTORS PRE-CLINICAL ACTIVITY/ SCREENING CLINICAL FOLLOW-UP DIAGNOSTIC & THERAPEUTIC PROCEDURES CANCER RECURRENCE AND MORTALITY CANCER CARE PREVALENCE SURVIVAL OCCURENCE EUROCHIP MAIN AXIS OF ANALYSIS CAMON EUROCARE/EUROPREVAL A METHOD FOR THE DISCUSSION

13. Steering Committee Working Team Operational work Panel of Experts Discussion & organization at national level Methodological Group Methodological aspects of the indicators GS: Groups of specialists Discussion of indicators at national and domain level GS GS GS GSGS GS GS A METHOD FOR THE ORGANISATION Standardised methods for collecting, checking and validating the data proposed for each indicator

14. A METHOD TO DESCRIBE THE INDICATORS For each indicator we compile a FORM DESIRED INDICATOR all indicator characteristics we wish to have  DESIRED INDICATOR: all indicator characteristics we wish to have METHODOLOGY operational definition, possible sources and methodological issues  METHODOLOGY: operational definition, possible sources and methodological issues AVAILABILITY different countries  AVAILABILITY in different countries

16. 130 130 CANCER SPECIALISTS ARE INVOLVED IN EUROCHIP 17 17 INTERNATIONAL MEETINGS HELD IN A YEAR 15 ALL 15 ALL COUNTRIES OF THE EUROPEAN UNION ARE PARTICIPATING IN THE PROJECT RESULTS

17. RESULTS PRELIMINARY LIST OF 158 INDICATORS 38 38 INDICATORS AT HIGH PRIORITY EUROCHIP MEETINGS

18. RESULT: INDICATORS AT HIGH PRIORITY * Connected with other HMP projects 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.Coverage of cancer registration 10.Incidence rates * 11.Survival rates * 12.Prevalence proportion * 13.Mortality rates * 14.Stage at diagnosis 15.Person-years life lost due to cancer 16.Completeness of the registration (DCO and Incidence / mortality) 17.% of microscopically cases *

19. 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

20. RESULTS: INDICATORS AT HIGH PRIORITY * Connected with other HMP projects 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 *

21. Life expectancy at birth $PPP Yrs I) GDP< 15611 72.4 II) 15611>GDP GDP<17538 76.7 III) GDP>17538 76.8 GDP and life expectancy at birth I, Estonia, Poland, Slovenia, Slovakia, and Spain; II, UK, Finland, Holland, Sweden, Italy, and Austria; III, Iceland, Denmark, France, Germany, and Switzerland

22. $PPPWorld-age-stand. incidence rate per 100,000 I) GDP< 15611216.4 II) 15611>GDP GDP<17538243.7 III) GDP>17538255.0 GDP and cancer incidence I, Estonia, Poland, Slovenia, Slovakia, and Spain; II, UK, Finland, Holland, Sweden, Italy, and Austria; III, Iceland, Denmark, France, Germany, and Switzerland

23. 5-year cancer relative survival $PPP % I) GDP< 1561133.4 II) 15611>GDP GDP<1753844.1 III) GDP>1753845.2 GDP and cancer survival I, Estonia, Poland, Slovenia, Slovakia, and Spain; II, UK, Finland, Holland, Sweden, Italy, and Austria; III, Iceland, Denmark, France, Germany, and Switzerland

24. Cancer prevalence $PPP proportion per 100,000 I) GDP< 156111030.3 II) 15611>GDP GDP<175381405.5 III) GDP>175381524.5 GDP and cancer prevalence I, Estonia, Poland, Slovenia, Slovakia, and Spain; II, UK, Finland, Holland, Sweden, Italy, and Austria; III, Iceland, Denmark, France, Germany, and Switzerland

25. World-age-stand. mortality World-age-stand. mortality I) GDP< 15611140.5 $PPP rate per 100,000 I) GDP< 15611140.5 II) 15611>GDP GDP<17538128.3 III) GDP>17538133.6 GDP and cancer mortality I, Estonia, Poland, Slovenia, Slovakia, and Spain; II, UK, Finland, Holland, Sweden, Italy, and Austria; III, Iceland, Denmark, France, Germany, and Switzerland

26. EUROCHIP PROVIDES METHODS FOR DISCUSSING AND PROVIDING ACCEPTED INDICATORS METHODS FOR DISCUSSING AND PROVIDING ACCEPTED INDICATORS A LIST OF INDICATORS FOR CANCER A LIST OF INDICATORS FOR CANCER A FUTURE BASE TO STUDY CANCER IN EUROPE WITH THE AIM TO REDUCE INEQUALITIES AND PROMOTE HEALTH 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

27. THOROUGHNESS OF THE INDICATOR LIST Dr. Andrea Micheli

28. LIST OF EUROCHIP HIGH PRIORITY INDICATORS Tobacco consumption Tobacco abstinence Exposure to asbestos PREVENTION Breast cancer screening coverage Cervical cancer screening coverage Colo-rectal cancer screening coverage Organised screening process indicators SCREENING Interval between diagnosis Interval between diagnosis and first treatment and first treatment Patients treated by surgery / chemotherapy / radiotherapy chemotherapy / radiotherapy Radiation equipment % of centres with at least 2 radiation equipments 2 radiation equipments CAT equipment Compliance with guidelines Palliative care teams TREATMENT AND CLINICAL ASP. Coverage of cancer registration Stage at diagnosis Person-years life lost due to cancer Completeness of the registration EPIDEMIOLOGY AND CANCER REG. Anti-tobacco regulations Indicators on Public Expendit. on Health for cancer on Health for cancer Indicators on Private Expend. on Health for cancer on Health for cancer MACRO SOCIAL- ECONOMIC VARIABLES

29. Occupational exposure other than asbestos (Update of CAREX) UV light HPV Pesticides ETS Recommendation/Legislation FIRST DISCUSSION

30. INDICATORS AT HIGH PRIORITY (1) * Connected with other HMP projects 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.Coverage of cancer registration 9.Incidence rates * 10.Survival rates * 11.Prevalence proportion * 12.Mortality rates * 13. Stage at diagnosis 14.Person-years life lost due to cancer 15.Completeness of the registration (DCO and Incidence / mortality) 16.% of microscopically cases *

31. INDICATORS AT HIGH PRIORITY (2) SCREENING Breast cancer screening coverage 17)Breast cancer screening coverage 18) Cervical cancer screening coverage 19)Colorectal cancer screening coverage 19) Colorectal cancer screening coverage 20)Organized screening process indicators 20) Organized screening process indicators TREATMENT AND CLINICAL ASPECTS Interval between diagnosis and first treatment 21)Interval between diagnosis and first treatment Radiation equipment 22)Radiation equipment % of centres with at least 2 radiation equipments 23)% of centres with at least 2 radiation equipments CAT Equipments 24)CAT Equipments Compliance with guidelines 25)Compliance with guidelines Patients treated by surgery / chemotherapy / radiotherapy 26)Patients treated by surgery / chemotherapy / radiotherapy Palliative care teams 27)Palliative care teams

32. INDICATORS AT HIGH PRIORITY (3) * Connected with other HMP projects 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 *

33. PRIORITYLEVELS Dr. Benedetto Terracini

34. PRIORITY LEVELS A A Direct indicator – Important – With or without any problem B B Indirect indicator – Important – With or without any problem C C Potentially useful but with presenting a great deal of problems D D Very low priority – Irrelevant

35. 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

36. B1 1.Tobacco sales 2.Tobacco price B2 connected with other HMP projects 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 C1 1.Radon expos in households 2.Exposure to PAH C2 connected with other HMP projects 1.Consumpt.of vegetable fibre 2.Consumption of meat 3.Cons. of processed meat OtherOthergroupsgroupsOtherOthergroupsgroups

37. INDICATORS ON TOBACCO

38. TOBACCO CONSUMPTION Simple indicator (only cigarettes) Complex indicator (all type of smoking) CONTEXT National survey & Health For All DB European survey SOURCE WHO suggests caution in comparison No problems with the European survey STANDARDIZATION No indications Relevant VARIABILITY Under reporting VALIDITY No indications Advanced conclusion: We suggest an European survey indipendently from the indicator choice

39. From HEALTH FOR ALL Database

40. CONTEXT SOURCE STANDARDIZATION VARIABILITY VALIDITY TOBACCO ABSTINENCE % past smokers who quitted tobacco smoking by time since quitting European survey No problems with the European survey Relevant No problems

41. 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?

42. EXPOSURE TO ASBESTOS

43. EXPOSURE TO ASBESTOS % Employers in naval dockyards Mortality trends for mesothelioma CONTEXT Difficult to find WHO Mortality Database SOURCE Problem of the exposure time No problems STANDARDIZATION No indications Exposure to asbestos is concentrated in small areas VARIABILITY Misclassification of cases VALIDITY Validation is really difficult Advanced conclusion: We suggest to use the mesothelioma mortality indicator

44. DISCUSSION ON Other eventual proxy for the indicator Misclassification of mesothelioma cases First suggestion Number of exposed workers to carcinogenic First suggestion: Update CAREX Database considering as indicator “Number of exposed workers to carcinogenic”

45. NEW INDICATORS

46. 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

47. EUROPEAN COMMISSION PUBLIC HEALTH PROGRAMS Dr. Andrea Micheli

48. PUBLIC HEALTH IN EUROPE the European past and next strategy FOCUS ON CANCER past/present in HMP: EUROCHIP and CAMON next: Working Party

49. Priority areas of the public health programme General health policy Health determinants Health threats Health information By Dr. Tapani Piha

50. Health information Bringing programmes together Cancer Injury Health monitoring Pollution Aids Rare diseases -2002 2003- By Dr. Tapani Piha

51. Health information Bringing programmes together Cancer Injury Health monitoring Pollution Aids Rare diseases -2002 2003- By Dr. Tapani Piha

52. 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

53. Stages in data processing Stage 1 Data definition and quality development Stage 2 Support to data collection at national level 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 By Dr. Tapani Piha

54. FINAL LIST OF INDICATORS

55. 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