EUROCHIP-2EUROCHIP-2

EUROCHIP-2 - The ActionEUROCHIP-2 - The Action

www.tumori.net/eurochipwww.tumori.net/eurochip

Public Health ProgramPublic Health ProgramEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERALEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL

EUROCHIP2:INEQUALITIES

IN CANCER MANAGEMENT

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)

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)

OUR INDICATIONS MUST REFER TO THE BEST STRATEGY FOR THE

DIFFUSSION OF BEST PRACTICE

METHODS OF EUROCHIP-2METHODS OF EUROCHIP-2

ACTIONS1. 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

Steering CommitteeSteering Committee

Working TeamWorking Team

Operational work

Panel of ExpertsPanel of ExpertsMethodological GroupMethodological Group

Methodological aspects Methodological aspects of the indicatorsof the indicators

GS: Groups of specialistsGS: Groups of specialists

a) Promotion of the action a) Promotion of the action at national level orat national level or

b) International domain b) International domain levellevel

(prevention, cancer (prevention, cancer epidemiology,epidemiology,

screening screening

care&treatment, care&treatment,

macro-indicators)macro-indicators)

GSGS

GS care and GS care and treatmenttreatment

GSGSGSGSGS

GSGS

GSGS

EUROCHIPEUROCHIP: THE ORGANISATION: THE ORGANISATION

Standardised methods for collecting, checking and validating the data proposed for each indicator

Cancer network

THE PROCESS APPROACH (Eurochip-2 form)THE PROCESS APPROACH (Eurochip-2 form)

Module (columns) and profile (rows)Module (columns) and profile (rows)

AIMS OF EUROCHIP-2AIMS 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

MAIN PRESENT GOAL OF THE MAIN PRESENT GOAL OF THE EUROCHIP-2 NETWORKEUROCHIP-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

TASKS OF THE NATIONAL GROUPSTASKS 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

THE ROLES OF DOMAIN GROUPSTHE 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

ACTIONS - e.g.: PolandACTIONS - 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

ACTIONS - e.g. (1): SwitzerlandACTIONS - 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 outAction: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

ACTIONS - e.g.(2): SwitzerlandACTIONS - e.g.(2): Switzerland

• Knowledge: There are no real data to evaluate cancer treatment, except for the Eurocare data in Geneva and BaselAction: 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

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

EUROCHIP-2 POSSIBLE FUND USEEUROCHIP-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

INDICATORS ON CARE & TREATMENTINDICATORS ON CARE & TREATMENTEuropean benchmarking in cancer careEuropean benchmarking in cancer care

Dr Ian KunklerDr Ian Kunkler

EUROCHIP-2 - The ActionEUROCHIP-2 - The Action

Public Health ProgramPublic Health ProgramEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERALEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL

PANEL OF EXPERTS’ Meeting – April 11PANEL OF EXPERTS’ Meeting – April 11thth,2005,2005

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

EUROCHIP 2 – care and treatment parameters

• Provision of CT scanners

• Provision of megavoltage RT units

• Delays in diagnosis and treatment

• Compliance with best practice

CTS EQUIPMENTCTS EQUIPMENT

WHAT?WHAT?

Number of diagnostic CT (Computed Axial Tomography or computed tomography scanners) systems per 1 000 000 population

WHY?WHY? Level of availability of diagnostic facilities

HOW?HOW? Health Ministry or Surveys

Computed Tomography Scanners – ITALY - MACROAREASComputed Tomography Scanners – ITALY - MACROAREAS

Source: Health for all - Italy Note: South Italy => Low survival

RADIATION EQUIPMENTRADIATION EQUIPMENT

WHAT?WHAT?Number of linear accelerators per 1 000 000 population

WHY?WHY? Availability of treatment facilities

HOW?HOW? Health Ministry or Surveys

RADIATION EQUIPMENT and CTS EQUIPMENTRADIATION EQUIPMENT and CTS EQUIPMENT PROCESS APPROACHPROCESS APPROACH

KNOWLEDGEKNOWLEDGE • Identification of availability in European countries• Comparison of equipment information collected in

different countries

CHOICECHOICE• Analysis of the European differences• Finding relations with cancer outcomes

ACTIONACTION• To promote acquisition of new equipments

Requirements for modern radiotherapy service

• 5.5.6.0 linear accelerators per 106 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

How much radiotherapy is needed and provided

• ESTRO QUARTS PROJECT

(QUAntification of Radiation Therapy Infrastructure and Staffing Needs

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)

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

National recommendations on linacs per 0.5 million population

• UK 2.0

• Spain 2.5

• France 3.6

• Czech Republic 1.4

Bentzen (2004)

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)

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)

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%)

Radiotherapy: linac provision 2000(Cottier,2004)

No

Linac

Italy

198

Holland

73

England

159France

275

Germany

363

%

MLC

34% 48% 22% 18% ?

Linac/

106 pop

3.43 4.59 3.21 4.70 4.42

Pop x106

57.7 15.8 49.4 58 81.9

No of linacs needed per 106 pop’nto reproduce SBU pattern of RT usage

• Hungary 11.2

• Denmark 5

• Ireland 3.6

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

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

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

DELAY OF CANCER TREATMENT: CONTEXTDELAY 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)

DELAY OF CANCER CAREDELAY OF CANCER CARE PROCESS APPROACHPROCESS APPROACH

KNOWLEDGEKNOWLEDGE • 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 outcomes

CHOICECHOICE • Analysing data coming from pilot studies

ACTIONACTION• Promotion of the diffusion of the pilot studies• Actions to reduce delay of cancer care

TODAY IN THE UK:TODAY IN THE UK:CANCER PLAN IN UK : WAITING TIMESCANCER PLAN IN UK : WAITING TIMES

• Maximum 1 month1 month wait from urgent GP referral to treatment guaranteed for children’s and testicular cancers and acute leukaemia

• Maximum 1 month1 month wait from diagnosis to treatment for breast cancer

• Maximum 1 month1 month wait from diagnosis to treatment for all cancers by 2005

• Maximum 2 months2 months wait from urgent GP referral to treatment for breast cancer

• Maximum 2 months2 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

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

COMPLIANCE WITH BEST ONCOLOGY PRACTICECOMPLIANCE WITH BEST ONCOLOGY PRACTICE PROCESS APPROACHPROCESS APPROACH

KNOWLEDGEKNOWLEDGE • Update of the High Resolution Studies Protocol to

collect data for these indicators• Identification of cancer registries where organise HR

Studies• Collection of the data

CHOICECHOICE • Analysing data coming from HR Studies

ACTIONACTION• Diffusion of the results

COMPLIANCE WITH BEST ONCOLOGY PRACTICECOMPLIANCE WITH BEST ONCOLOGY PRACTICE

The indicator aims to reflect the compliance with best practices in oncology. BREASTProportion of patients receiving post-operative breast radiotherapy after breast conserving surgery Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded) COLONProportion 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 LUNGProportion of patients with non small cell undergoing radical surgery Proportion of patients undergoing staging with thoracic CT scanning CERVIXProportion 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)

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?)

PROPORTION OF PATIENTS TREATED WITH PROPORTION OF PATIENTS TREATED WITH PALLIATIVE RADIOTHERAPYPALLIATIVE RADIOTHERAPY

WHAT?WHAT?Number of patients who have received palliative radiotherapy

WHY?WHY? Quality of life for incurable cancer patients

HOW?HOW? Survey on radiotherapy units

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

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

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 35-187)O’Rourke N Clin Oncol

2000;12:141-4

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

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

DECISIONSDECISIONS

EUROCHIP-2 - The ActionEUROCHIP-2 - The Action

Public Health ProgramPublic Health ProgramEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERALEUROPEAN COMMISSION: HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL

PANEL OF EXPERTS’ Meeting – April 11PANEL OF EXPERTS’ Meeting – April 11thth,2005,2005

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

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

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)

COMPLIANCE WITH BEST ONCOLOGY PRACTICECOMPLIANCE WITH BEST ONCOLOGY PRACTICE

The indicator aims to reflect the compliance with best practices in oncology. BREASTProportion of patients receiving post-operative breast radiotherapy after breast conserving surgery Proportion of breast conservation surgery in pT1 cases (multiple cancers excluded) COLONProportion 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 LUNGProportion of patients with non small cell undergoing radical surgery Proportion of patients undergoing staging with thoracic CT scanning CERVIXProportion 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)

TODAY IN UK:TODAY IN UK:CANCER PLAN IN UK: CARE & TREATMENTCANCER 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