Progress, challenges and ways forward supporting cancer surveillance in Latin America.

Population-based cancer registries (PBCRs) are the only means to provide reliable incidence and survival data as a basis for policy-making and resource allocations within cancer care. Yet, less than 3% and 10% of the respective populations of Central America and South America are covered by high-quality cancer registries. The Global Initiative for Cancer Registry Development provides support to improve this situation via the International Agency for Research on Cancer Regional Hub for Latin America. In this paper, we summarize activities (advocacy, technical assistance, training and research) over the last 5 years, their impact and current challenges, including the implementation of new PBCR in four countries in the region. Despite the favorable political support to cancer registration in many countries, the sustainability of cancer registration remains vulnerable. Renewed efforts are needed to improve data quality in Latin America while ensuring maximum visibility of the data collected by disseminating and promoting their use in cancer control.

TNFR-associated factor 2 deficiency in B lymphocytes predisposes to chronic lymphocytic leukemia/small lymphocytic lymphoma in mice.

We have previously shown that transgenic (tg) mice expressing in B lymphocytes both BCL-2 and a TNFR-associated factor 2 (TRAF2) mutant lacking the really interesting new gene and zinc finger domains (TRAF2DN) develop small lymphocytic lymphoma and chronic lymphocytic leukemia with high incidence (Zapata et al. 2004. Proc. Nat. Acad. Sci. USA 101: 16600-16605). Further analysis of the expression of TRAF2 and TRAF2DN in purified B cells demonstrated that expression of both endogenous TRAF2 and tg TRAF2DN was negligible in Traf2DN-tg B cells compared with wild-type mice. This was the result of proteasome-dependent degradation, and rendered TRAF2DN B cells as bona fide TRAF2-deficient B cells. Similar to B cells with targeted Traf2 deletion, Traf2DN-tg mice show expanded marginal zone B cell population and have constitutive p100 NF-κB2 processing. Also, TRAF3, X-linked inhibitor of apoptosis, and Bcl-X(L) expression levels were increased, whereas cellular inhibitors of apoptosis 1 and 2 levels were drastically reduced compared with those found in wild-type B cells. Moreover, consistent with previous results, we also show that TRAF2 was required for efficient JNK and ERK activation in response to CD40 engagement. However, TRAF2 was deleterious for BCR-mediated activation of these kinases. In contrast, TRAF2 deficiency had no effect on CD40-mediated p38 MAPK activation but significantly reduced BCR-mediated p38 activation. Finally, we further confirm that TRAF2 was required for CD40-mediated proliferation, but its absence relieved B cells of the need for B cell activating factor for survival. Altogether, our results suggest that TRAF2 deficiency cooperates with BCL-2 in promoting chronic lymphocytic leukemia/small lymphocytic lymphoma in mice, possibly by specifically enforcing marginal zone B cell accumulation, increasing X-linked inhibitor of apoptosis expression, and rendering B cells independent of B cell activating factor for survival.

An updated profile of the cancer burden, patterns and trends in Latin America and the Caribbean.

Background: Cancer is a leading cause of disease and death in Latin America and the Caribbean (LAC). Contemporary data on the cancer burden aims to inform effective cancer policies; this article provides an update and benchmarking of national cancer incidence and mortality estimates for the year 2020, alongside recent mortality trends in the region. Methods: The number of new cancer cases and deaths were extracted from the GLOBOCAN 2020 database developed by the International Agency for Research on Cancer (IARC), and mortality data over time from IARC's cancer mortality database, New cancer cases, deaths and corresponding age-standardized rates per 100,000 person-years are presented. Random fluctuations in mortality trends by country, sex and cancer site were smoothed using LOWESS regression. Findings: An estimated total of 1.5 million new cancer cases and 700,000 deaths occur annually in LAC, with corresponding incidence and mortality rates of 186.5 and 86.6 per 100,000. The most common cancers in 2020 were prostate (15%), breast (14%), colorectal (9%), lung (7%) and stomach (5%). Lung cancer remained the leading cause of cancer death (12%), though rates varied substantially between countries. The mortality trends of infectious-related cancers tended to decline in most countries, while rates of cancer types linked to westernization were mainly increasing. Assuming rates remain unchanged, the cancer burden in LAC will increase by 67% reaching 2.4 million new cases annually by 2040. Interpretation: The cancer patterns reflect important underlying sociodemographic changes occurring over the last decades. With an increasing burden anticipated over the next decades in this region, there is a need to plan oncological service provision accordingly. Funding: No external funds received.

Cancer incidence estimates and mortality for the top five cancer in Colombia, 2007-2011.

OBJECTIVES: To describe the incidence and mortality for the five main types of cancer in Colombia, from 2007-2011. METHODS: We estimated cases and cancer incidence rates standardised by age, based on incidence/mortality ratios; and we calculated the observed deaths and mortality rates standardised by age in Colombia, both differentiated by province, type of cancer and sex. Incidence estimates were generated based on information from four cancer population registries (Cali, Pasto, Bucaramanga and Manizales), published in Cancer Incidence in Five Continents, volume X, and the official mortality and population information of the National Administrative Province of Statistics (DANE, for its initials in Spanish). RESULTS: The annual number of expected cases (all cancers) was 62,818 in men and women; and there were 32,653 recorded deaths. The main incidental cancers were prostate (46.5 per 100,000 person-years) in men, and breast (33.8 per 100,000 person-years) in women. The highest mortality figures were for stomach cancer in men (14.2); and breast cancer in women (9.9). CONCLUSIONS: The highest incidence and mortality estimates in Colombia were for breast and prostate cancers, as well as a proportion of infection-related cancers, such as stomach and cervical cancer. These four neoplasms were responsible for more than 50% of the burden of the disease. Only through good quality, long-duration cancer registries, can information be obtained about the changes in incidence trends.

OBJETIVOS: Describir la incidencia y mortalidad para los cinco principales tipos de cáncer en Colombia, de 2007-2011. MÉTODOS: Se estimaron casos y tasas de incidencia de cáncer ajustadas por edad a partir de razones incidencia/mortalidad y se calcularon las muertes observadas y tasas de mortalidad ajustadas por edad en Colombia, ambas diferenciadas por departamentos, tipo de cáncer y sexo. Las estimaciones de incidencia se generaron con base en la información de cuatro registros poblacionales de cáncer (Cali, Pasto, Bucaramanga y Manizales), publicada en Cancer Incidence in Five Continents, volumen X, y la información oficial de mortalidad y población del Departamento Administrativo Nacional de Estadística (DANE). RESULTADOS: El número anual de casos esperados (todos los cánceres) fue 62,818 en hombres y en mujeres y se registraron 32,653 muertes. Los principales cánceres incidentes fueron próstata (46.5 por 100,000 años-persona) en hombres y mama (33.8 por 100,000 años-persona) en mujeres. La mortalidad más alta en hombres se presentó en estómago (14.2) y mama en mujeres (9.9). CONCLUSIONES: Las estimaciones de incidencia y mortalidad más altas en Colombia fueron para los cánceres de mama y próstata, además de una proporción de cánceres relacionados con la infección como son el cáncer de estómago y de cuello uterino. Estas cuatro neoplasias fueron responsables de más del 50% de la carga de la enfermedad. Solamente a través de los registros de cáncer de buena calidad y de larga trayectoria podrá tenerse información sobre el cambio en las tendencias de incidencia.

Quality of death certification in Colombia.

OBJECTIVE: To evaluate the quality of the certification of general death and cancer in Colombia. METHODS: Validity indicators were described for each province and the cities of Bogotá, Cali, Manizales, Pasto and Bucaramanga. A factorial analysis of principal components was carried out in order to identify non-obvious relationships. RESULTS: Were analyzed 984,159 deaths, among them there were 164,542 deaths due to cancer. 93.7% of the general mortality was well certified. The predominant errors were signs, symptoms and ill-defined conditions. 92.8% of cancer mortality was well certified. The predominant errors were due to poorly defined cancer sites. CONCLUSIONS: Certification of quality indicators in Colombia has improved. Given the good performance of the quality indicators for certificating general death and cancer, it is considered that this is a valid input for the estimation of cancer incidences.

OBJETIVO: Evaluar la calidad de la certificación de la muerte general y por cáncer en Colombia. MÉTODOS: Se describieron indicadores de validez para cada departamento y las ciudades de Bogotá, Cali, Manizales, Pasto y Bucaramanga. Se realizó un análisis factorial de componentes principales con el fin de identificar relaciones no evidentes. RESULTADOS: Se analizaron 984,159 defunciones, dentro de las cuales había 164,542 muertes por cáncer. El 93.7% de la mortalidad general estaba bien certificada. Los errores predominantes fueron signos, síntomas y afecciones mal definidas. El 92.8% de la mortalidad por cáncer estaba bien certificada. Los errores predominantes fueron cánceres de sitio mal definido. CONCLUSIONES: Los indicadores de calidad de certificación en Colombia mejoraron. Ante el buen comportamiento de los indicadores de calidad de la certificación de la muerte general y por cáncer, se considera que ésta es un insumo válido para la estimación de incidencia de cáncer.

Breast and cervical cancer survival at Instituto Nacional de Cancerología, Colombia.

OBJECTIVE: to provide and compare estimations of two-year overall survival for cervical and female breast cancer in three cohorts (first treated in 2007, 2010, 2012) at the Instituto Nacional de Cancerología of Colombia. METHODS: All patients first treated at the Instituto Nacional de Cancerología for breast or cervical cancer in the years 2007, 2010, 2012, without a prior cancer diagnosis, were included for the study. The hospital-based cancer registry was cross linked with governmental databases to obtain follow-up information on all patients. Probability of surviving 24 months since the date of entry at the hospital was estimated using Kaplan-Meier methods, using the log-rank test to evaluate differences between groups. RESULTS: We analyzed 1,928 breast cancer cases and 1,189 cervical cancer cases, resulting in an overall survival probability at 24 months of 79.6% (95% CI: 77.8-81.4) for BC and of 63.3% (95% CI: 60.6- 66.0) for cervical cancer, there were no differences in survival for year of entry. Advanced clinical stage substantially affected overall survival, being 32.2% (95% CI: 28.4-44.0) for stage IV breast cancer and 22.6% (95% CI: 11.4-33.8) for stage IV cervical cancer. CONCLUSIONS: Breast cancer was the cancer with the best survival rates at Instituto Nacional de Cancerología; cervical cancer was the one with the lowest survival rates. Overall survival did not change over the years for any of the cancers.

OBJETIVO: Describir las estimaciones de supervivencia global a dos años para mama (mujeres) y cuello uterino en tres cohortes (tratadas por primera vez en 2007, 2010, 2012) en el Instituto Nacional de Cancerología de Colombia. MÉTODOS: Se incluyeron las pacientes tratadas por primera vez en el Instituto Nacional de Cancerología por cáncer de mama y de cuello uterino en los años 2007, 2010, y 2012, y quienes no habían tenido un diagnóstico previo de otro cáncer. Se cruzaron las bases de datos del registro hospitalario de cáncer con las gubernamentales para obtener información de seguimiento de los casos. Se estimó la probabilidad de sobrevivir a 24 meses a partir de la fecha de ingreso mediante el método de Kaplan-Meier. Se aplicó la prueba de rango logarítmico para evaluar las diferencias entre los grupos. RESULTADOS: Se analizaron 1,928 casos de cáncer de mama y 1,189 de cuello uterino. La estimación de la supervivencia global a 24 meses para mama fue 79.6% (IC 95%: 77.8-81.4) y de 63.3% (IC 95%: 60.6-66.0) para cuello uterino, no se observaron tendencias en supervivencia con el año de ingreso. En los estadios clínicos avanzados la supervivencia global disminuyó en estadio clínico IV, tanto para cáncer de mama, 32.2% (IC 95%: 28.4-44.0), como para cuello uterino 22.6% (IC 95%: 11.4-33.8). CONCLUSIONES: El cáncer de mama presentó mejor supervivencia en el Instituto Nacional de Cancerología frente al cáncer de cuello uterino. La supervivencia global se comportó de manera estable con los años para ambos tipos de cáncer.

Oncology services supply in Colombia.

OBJECTIVE: To characterize the current status of oncological services supply in Colombia. METHODS: A descriptive analysis of oncological services for cancer care in the adult and infant population that meet the requirements for operation according to the Special Register of Health Service Providers was carried out. The case - by - provider ratio was calculated based on the cancer incidence estimated for Colombia by the National Cancer Institute. RESULTS: Were identified 1,780 qualified oncology health services in the country related to specialties for providing care to cancer patients. Twenty five providers nationwide had all three qualified services: chemotherapy, radiotherapy and surgery. Nearly 50% of the offer was concentrated in Bogotá, Antioquia and Valle del Cauca. Putumayo and the Amazonas group departments, with the exception of Vaupés, did not show any oncological services. Healthcare Providers were responsible for 87.8%, and independent professionals provided 12.2%. Outpatient services were 66.7% of oncology services, 17.4% was diagnostic support services and therapeutic complementation, and 15.9% was surgical services. 87.9% of the oncological service offer in Colombia takes place in the private sector. CONCLUSIONS: The ratio between the service groups is asymmetric, with few providers jointly offering the basic services for oncology treatment, which reflects how provision is fragmented. It is necessary to redefine the concept of oncology service under a comprehensive care approach and the importance of enabling functional units, comprehensive treatment centers and other forms of care.

OBJETIVO: Caracterizar la situación actual de la oferta de servicios oncológicos en Colombia. MÉTODOS: Se realizó un análisis descriptivo de los servicios oncológicos para la atención de cáncer en población adulta e infantil, que cumplieron con los requisitos para su funcionamiento de acuerdo al Registro Especial de Prestadores de Servicios de Salud. La razón de casos por prestador se calculó a partir de la incidencia de cáncer estimada para Colombia por el Instituto Nacional de Cancerología. RESULTADOS: Se identificaron 1,780 servicios de salud oncológicos habilitados en el país relacionados con especialidades para la atención de pacientes con cáncer. 25 prestadores a nivel nacional contaron con los tres servicios habilitados: quimioterapia, radioterapia y cirugía. Cerca del 50% de la oferta se concentró en Bogotá, Antioquia y Valle del Cauca. Los departamentos de Putumayo y del grupo Amazonas, con excepción de Vaupés, no registraron servicios oncológicos. El 87.8% fue ofertado por Instituciones Prestadoras de Salud y el 12.2% fue provisto por profesionales independientes. El 66.7% de los servicios oncológicos eran de consulta externa, el 17.4% eran servicios de apoyo diagnóstico y complementación terapéutica y el 15.9% servicios quirúrgicos. El 87.9% de la oferta de servicios oncológicos en Colombia está en el sector privado. CONCLUSIONES: La relación entre los grupos de servicios es asimétrica, con pocos prestadores que ofertan de forma conjunta los servicios bases del tratamiento oncológico, lo cual refleja la fragmentación en la prestación. Es necesario redefinir el concepto de servicio oncológico bajo el enfoque de atención integral y la importancia de habilitar unidades funcionales, centros integrales de tratamiento y otras formas de atención.

Time trends in educational inequalities in cancer mortality in Colombia, 1998-2012.

OBJECTIVES: To evaluate trends in premature cancer mortality in Colombia by educational level in three periods: 1998-2002 with low healthcare insurance coverage, 2003-2007 with rapidly increasing coverage and finally 2008-2012 with almost universal coverage (2008-2012). SETTING: Colombian population-based, national secondary mortality data. PARTICIPANTS: We included all (n=188,091) cancer deaths occurring in the age group 20-64 years between 1998 and 2012, excluding only cases with low levels of quality of registration (n=2902, 1.5%). PRIMARY AND SECONDARY OUTCOME MEASURES: In this descriptive study, we linked mortality data of ages 20-64 years to census data to obtain age-standardised cancer mortality rates by educational level. Using Poisson regression, we modelled premature mortality by educational level estimating rate ratios (RR), relative index of inequality (RII) and the Slope Index of Inequality (SII). RESULTS: Relative measures showed increased risks of dying among the lower educated compared to the highest educated; this tendency was stronger in women (RRprimary 1.49; RRsecondary 1.22, both p<0.0001) than in men (RRprimary 1.35; RRsecondary 1.11, both p<0.0001). In absolute terms (SII), cancer caused a difference per 100 000 deaths between the highest and lowest educated of 20.5 in males and 28.5 in females. RII was significantly higher among women and the younger age categories. RII decreased between the first and second periods; afterwards (2008-2012), it increased significantly back to their previous levels. Among women, no significant increases or declines in cancer mortality over time were observed in recent periods in the lowest educated group, whereas strong recent declines were observed in those with secondary education or higher. CONCLUSIONS: Educational inequalities in cancer mortality in Colombia are increasing in absolute and relative terms, and are concentrated in young age categories. This trend was not curbed by increases in healthcare insurance coverage. Policymakers should focus on improving equal access to prevention, early detection, diagnostic and treatment facilities.

Estimating the cost of operating cancer registries: Experience in Colombia.

BACKGROUND: Maintaining population-based registries requires adequate and sustained resources; however, to date there has been no systematic evaluation to identify the resource needs for cancer registration in most countries, including Colombia. A systematic assessment of the costs can quantify the funding required and identify processes to improve efficiency of cancer registries. METHODS: The Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool) was tailored specifically for the Colombian registries and was used to collect resource use data from five regional population-based cancer registries: Barranquilla, Bucaramanga, Cali, Manizales, and Pasto. The registries provided cost data for the year 2013 and cancer cases corresponding to the year 2010. RESULTS: We identified an almost threefold variation in the average cost per case (77,932 to 214,082 Colombian pesos or US $41 to US $113 in 2013) across the registries, but there were also substantial differences in data collection approaches, types of data collected, and activities performed. Cost per inhabitant varied between 95 and 415 Colombian pesos (US $0.05 to US $0.22). Between 20% and 45% of the total cost was due to fixed cost activities. CONCLUSIONS: The detailed economic information presented in this study constitutes a valuable source of activity-based cost data that registries can use to compare operations, assess key factors that lead to differences in cost per case, and identify potential approaches to improve efficiencies. Furthermore, the knowledge gained from studying the Colombian registries can help inform the planning and operations of other registries in the region.

Gastric cancer survival and affiliation to health insurance in a middle-income setting.

OBJECTIVE: To investigate whether health insurance affiliation and socioeconomic deprivation is associated with overall cause survival from gastric cancer in a middle-income country. METHODS: All patients resident in the Bucaramanga metropolitan area (Colombia) diagnosed with gastric cancer between 2003 and 2009 (n=1039), identified in the population-based cancer registry, were followed for vital status until 31/12/2013. Kaplan-Meier models provided crude survival estimates by health insurance regime (HIR) and social stratum (SS). Multivariate Cox-proportional hazard models adjusting HIR and SS for sex, age and tumor grade, were performed. RESULTS: Overall 1 and 5 year survival proportions were 32.4% and 11.0%, respectively, varying from 49.3% and 15.8% for patients affiliated to the most generous HIR to 12.9% and 5.3% for unaffiliated patients, and from 41.4% and 20.7% for patients in the highest SS, versus 27.1% and 7.4% for the lowest SS. The multivariate analyses showed type of HIR as well as SS to remain independently associated with survival, with an 11% improvement in survival for each increase in SS subgroup (HR 0.89 (95% CI 0.83; 0.96), and with worse survival in the subsidized (least generous) HIR and unaffiliated patients compared to the contributory HIR (HR subsidized 1.20 (95% CI 1.00; 1.43) and HR not affiliated 2.03 (95% CI 1.48; 2.78)). Of the non-affiliated patients, 60% had died at the time of diagnosis, versus 4-14% of affiliated patients (p<0.0005). CONCLUSIONS: Despite the 'universal' health insurance system, large socioeconomic differences in gastric cancer survival exist in Colombia. Both social stratum and access to effective diagnostic and curative care strongly influence survival.

Trends in inequalities in premature cancer mortality by educational level in Colombia, 1998-2007.

BACKGROUND: There is a paucity of studies on socioeconomic inequalities in cancer mortality in developing countries. We examined trends in inequalities in cancer mortality by educational attainment in Colombia during a period of epidemiological transition and rapid expansion of health insurance coverage. METHODS: Population mortality data (1998-2007) were linked to census data to obtain age-standardised cancer mortality rates by educational attainment at ages 25-64 years for stomach, cervical, prostate, lung, colorectal, breast and other cancers. We used Poisson regression to model mortality by educational attainment and estimated the contribution of specific cancers to the slope index of inequality in cancer mortality. RESULTS: We observed large educational inequalities in cancer mortality, particularly for cancer of the cervix (rate ratio (RR) primary vs tertiary groups=5.75, contributing 51% of cancer inequalities), stomach (RR=2.56 for males, contributing 49% of total cancer inequalities and RR=1.98 for females, contributing 14% to total cancer inequalities) and lung (RR=1.64 for males contributing 17% of total cancer inequalities and 1.32 for females contributing 5% to total cancer inequalities). Total cancer mortality rates declined faster among those with higher education, with the exception of mortality from cervical cancer, which declined more rapidly in the lower educational groups. CONCLUSIONS: There are large socioeconomic inequalities in preventable cancer mortality in Colombia, which underscore the need for intensifying prevention efforts. Reduction of cervical cancer can be achieved through reducing human papilloma virus infection, early detection and improved access to treatment of preneoplastic lesions. Reinforcing antitobacco measures may be particularly important to curb inequalities in cancer mortality.

Supervivencia de pacientes con cáncer epitelial de ovario en el Instituto Nacional de Cancerología, resultados a partir del registro hospitalario de cáncer (2005-2014) / Survival of patients with epithelial ovarian cancer, results of the hospital-based cancer registry of the National Cancer Institute (2005-2014)

Resumen Objetivo: Proporcionar características demográficas y clínicas, así como estimaciones de supervivencia global a tres años de pacientes con cáncer epitelial de ovario (CEO) tratadas entre 2005 y 2014 en el Instituto Nacional de Cancerología de Colombia (INC). Métodos: Se incluyeron 783 pacientes diagnosticadas y tratadas por primera vez en el INC por CEO en los periodos 2005-2008, 2009-2011 y 2012-2014 sin un diagnóstico previo de otro cáncer. Se cruzaron datos del registro hospitalario de cáncer con bases de datos gubernamentales para obtener información de seguimiento. Utilizando el método Kaplan-Meier se estimó la probabilidad de sobrevivir a 36 meses a partir de la fecha de ingreso, evaluando diferencias en supervivencia entre grupos con la prueba de rango logarítmico. Se utilizaron modelos multivariados de riesgos proporcionales de Cox para evaluar: el efecto relativo de edad, el estadio clínico, el subtipo histológico y el tipo de tratamiento inicial en la supervivencia. Resultados: La probabilidad de supervivencia global a 36 meses fue de 56,5% (IC 95%: 53,0; 60,0), que se mantuvo estable en los tres periodos. La edad avanzada, el estadio clínico y el subtipo histológico afectaron significativamente la supervivencia global a tres años: 49,5% (IC 95%: 43; 55,6) para mujeres >59 años; 21,9% (IC 95%: 14,7; 29,2) para la enfermedad en estadio IV y 56,3% (IC 95%: 37,5; 54,3) para los tumores serosos. Las estimaciones de hazard fueron significativamente más altas en pacientes de 59 años o más (HR 1,54 (IC del 95%: 1,04 a 2,27)) y en cánceres con estadio avanzado (HR 13,47 (IC 95%: 7,92-22,92)); la cirugía más quimioterapia tuvo una reducción en el riesgo en comparación con otros tratamientos (HR 0,84 (IC 95% 0,52-1,36). Conclusiones: La supervivencia del cáncer epitelial de ovario se mantuvo estable con el tiempo. La variación se presentó en factores como: la edad, el estadio clínico y el primer tratamiento.

Abstract Aims: To provide demographical and clinical characteristics and estimations of 3-year overall survival of epithelial ovarian cancer (EOC) patients treated at the Colombian National Cancer Institute (INC) between 2005 and 2014. Methods: All 783 patients first treated at INC for EOC in the three periods: (2005-2008, 2009-2011, 2012-2014), without a prior cancer diagnosis, were included in this study. Follow-up was realized by cross-linkage with governmental databases using person identification numbers. Probability of surviving 36 months since the date of entry at INC was estimated using Kaplan-Meier methods, using the log-rank test to evaluate differences between groups. We used multivariate Cox proportional hazard models to evaluate the relative effect of age, clinical stage, histological subtype and treatment first on survival. Results: The overall survival probability at 36 months was 56.5% (95% CI: 53.0, 60.0), which was stable over time. Advanced age and clinical stage significantly affected 3-year overall survival, being 49.5°% (95°% CI: 43.4, 55.6) for age > 59, 21.9°% (95°% CI: 14.7, 29.2) for stage IV disease and 56.3% (95% CI: 37.5, 54.3) for serous tumors. Hazard ratios were significantly higher for patients aged 59 and over (HR 1.54 (95%CI 1.04-2.27)) and advanced stage cancers (HR 13.47 (95%CI 7.92-22.92)), whereas patients with surgery plus chemotherapy had a strongly reduced risks compared to other treatments (HR 0.84 (95%CI 0.52-1.36)). Conclusions: Survival of epithelial ovarian cancer was stable over time, with a variation according to age, clinical stage and first treatment.

Comprehensive assessment of population-based cancer registries: an experience in Colombia.

BACKGROUND: In the global context, the establishment of population-based cancer registries, particularly in less developed regions, has become of strategic importance. The factors influencing the operation and sustainability of registries can be determinants for their success, despite the existence of uniform quality indicators in the cancer incidence information. Our objective was to determine the current state of the structure, organization and operation of populationbased cancer registries in Colombia, obtain information on their degree of development and identify specific problems that affect their operation and sustainability. METHODS: We developed a descriptive study in 5 population-based cancer registries (Barranquilla, Bucaramanga, Cali, Manizales, and Pasto). The analysis included 7 broad categories: general characteristics, operational procedures, scientific production, completeness, validity, comparability and continuing education. To establish the validity of the information we used the available incidence databases. RESULTS: All registries were based in a university (3 public, 2 private). The 5 registries covered 11.8 percent of the Colombian population. Four registries published their results on cancer incidence. Financing came from different sources and costs varied significantly. Cancer incidence rates ranged from 94.1 to 189.2 per 100,000. The coverage of information sources ranged from 60 to 90 percent. Validity indicators were within acceptable limits while comparability parameters showed variations between registries. All registries participated in regular workshops and congresses. CONCLUSIONS: Operation of cancer registries in a model with universities and with several financial sources seems to provide sustainability; follow-up, training and assistance are critical to motivation and quality, costs vary significantly and determinants of costs of registry activities need to be further assessed.

Cancer incidence estimates and mortality for the top five cancer in Colombia, 2007-2011 / Estimaciones de incidencia y mortalidad para los principales cinco tipos de cáncer en Colombia, 2007-2011

Abstract Objectives: To describe the incidence and mortality for the five main types of cancer in Colombia, from 2007-2011. Methods: We estimated cases and cancer incidence rates standardised by age, based on incidence/mortality ratios; and we calculated the observed deaths and mortality rates standardised by age in Colombia, both differentiated by province, type of cancer and sex. Incidence estimates were generated based on information from four cancer population registries (Cali, Pasto, Bucaramanga and Manizales), published in Cancer Incidence in Five Continents, volume X, and the official mortality and population information of the National Administrative Province of Statistics (DANE, for its initials in Spanish). Results: The annual number of expected cases (all cancers) was 62,818 in men and women; and there were 32,653 recorded deaths. The main incidental cancers were prostate (46.5 per 100,000 person-years) in men, and breast (33.8 per 100,000 person-years) in women. The highest mortality figures were for stomach cancer in men (14.2); and breast cancer in women (9.9). Conclusions: The highest incidence and mortality estimates in Colombia were for breast and prostate cancers, as well as a proportion of infection-related cancers, such as stomach and cervical cancer. These four neoplasms were responsible for more than 50% of the burden of the disease. Only through good quality, long-duration cancer registries, can information be obtained about the changes in incidence trends.

Resumen Objetivos: Describir la incidencia y mortalidad para los cinco principales tipos de cáncer en Colombia, de 2007-2011. Métodos: Se estimaron casos y tasas de incidencia de cáncer ajustadas por edad a partir de razones incidencia/mortalidad y se calcularon las muertes observadas y tasas de mortalidad ajustadas por edad en Colombia, ambas diferenciadas por departamentos, tipo de cáncer y sexo. Las estimaciones de incidencia se generaron con base en la información de cuatro registros poblacionales de cáncer (Cali, Pasto, Bucaramanga y Manizales), publicada en Cancer Incidence in Five Continents, volumen X, y la información oficial de mortalidad y población del Departamento Administrativo Nacional de Estadística (DANE). Resultados: El número anual de casos esperados (todos los cánceres) fue 62,818 en hombres y en mujeres y se registraron 32,653 muertes. Los principales cánceres incidentes fueron próstata (46.5 por 100,000 años-persona) en hombres y mama (33.8 por 100,000 años-persona) en mujeres. La mortalidad más alta en hombres se presentó en estómago (14.2) y mama en mujeres (9.9). Conclusiones: Las estimaciones de incidencia y mortalidad más altas en Colombia fueron para los cánceres de mama y próstata, además de una proporción de cánceres relacionados con la infección como son el cáncer de estómago y de cuello uterino. Estas cuatro neoplasias fueron responsables de más del 50% de la carga de la enfermedad. Solamente a través de los registros de cáncer de buena calidad y de larga trayectoria podrá tenerse información sobre el cambio en las tendencias de incidencia.

Breast and cervical cancer survival at Instituto Nacional de Cancerología, Colombia / Supervivencia al cáncer de mama y cervix en el Instituto Nacional de Cancerología, Colombia

Abstract Objective: to provide and compare estimations of two-year overall survival for cervical and female breast cancer in three cohorts (first treated in 2007, 2010, 2012) at the Instituto Nacional de Cancerología of Colombia Methods: All patients first treated at the Instituto Nacional de Cancerología for breast or cervical cancer in the years 2007, 2010, 2012, without a prior cancer diagnosis, were included for the study. The hospital-based cancer registry was cross linked with governmental databases to obtain follow-up information on all patients. Probability of surviving 24 months since the date of entry at the hospital was estimated using Kaplan-Meier methods, using the log-rank test to evaluate differences between groups. Results: We analyzed 1,928 breast cancer cases and 1,189 cervical cancer cases, resulting in an overall survival probability at 24 months of 79.6% (95% CI: 77.8-81.4) for BC and of 63.3% (95% CI: 60.6- 66.0) for cervical cancer, there were no differences in survival for year of entry. Advanced clinical stage substantially affected overall survival, being 32.2% (95% CI: 28.4-44.0) for stage IV breast cancer and 22.6% (95% CI: 11.4-33.8) for stage IV cervical cancer. Conclusions: Breast cancer was the cancer with the best survival rates at Instituto Nacional de Cancerología; cervical cancer was the one with the lowest survival rates. Overall survival did not change over the years for any of the cancers.

Resumen Objetivo: Describir las estimaciones de supervivencia global a dos años para mama (mujeres) y cuello uterino en tres cohortes (tratadas por primera vez en 2007, 2010, 2012) en el Instituto Nacional de Cancerología de Colombia. Métodos: Se incluyeron las pacientes tratadas por primera vez en el Instituto Nacional de Cancerología por cáncer de mama y de cuello uterino en los años 2007, 2010, y 2012, y quienes no habían tenido un diagnóstico previo de otro cáncer. Se cruzaron las bases de datos del registro hospitalario de cáncer con las gubernamentales para obtener información de seguimiento de los casos. Se estimó la probabilidad de sobrevivir a 24 meses a partir de la fecha de ingreso mediante el método de Kaplan-Meier. Se aplicó la prueba de rango logarítmico para evaluar las diferencias entre los grupos. Resultados: Se analizaron 1,928 casos de cáncer de mama y 1,189 de cuello uterino. La estimación de la supervivencia global a 24 meses para mama fue 79.6% (IC 95%: 77.8-81.4) y de 63.3% (IC 95%: 60.6-66.0) para cuello uterino, no se observaron tendencias en supervivencia con el año de ingreso. En los estadios clínicos avanzados la supervivencia global disminuyó en estadio clínico IV, tanto para cáncer de mama, 32.2% (IC 95%: 28.4-44.0), como para cuello uterino 22.6% (IC 95%: 11.4-33.8). Conclusiones: El cáncer de mama presentó mejor supervivencia en el Instituto Nacional de Cancerología frente al cáncer de cuello uterino. La supervivencia global se comportó de manera estable con los años para ambos tipos de cáncer.

Quality of death certification in Colombia / Calidad de la certificación de la muerte en Colombia

Abstract Objective: To evaluate the quality of the certification of general death and cancer in Colombia. Methods: Validity indicators were described for each province and the cities of Bogotá, Cali, Manizales, Pasto and Bucaramanga. A factorial analysis of principal components was carried out in order to identify non-obvious relationships. Results: Were analyzed 984,159 deaths, among them there were 164,542 deaths due to cancer. 93.7% of the general mortality was well certified. The predominant errors were signs, symptoms and ill-defined conditions. 92.8% of cancer mortality was well certified. The predominant errors were due to poorly defined cancer sites. Conclusions: Certification of quality indicators in Colombia has improved. Given the good performance of the quality indicators for certificating general death and cancer, it is considered that this is a valid input for the estimation of cancer incidences.

Resumen Objetivo: Evaluar la calidad de la certificación de la muerte general y por cáncer en Colombia. Métodos: Se describieron indicadores de validez para cada departamento y las ciudades de Bogotá, Cali, Manizales, Pasto y Bucaramanga. Se realizó un análisis factorial de componentes principales con el fin de identificar relaciones no evidentes. Resultados: Se analizaron 984,159 defunciones, dentro de las cuales había 164,542 muertes por cáncer. El 93.7% de la mortalidad general estaba bien certificada. Los errores predominantes fueron signos, síntomas y afecciones mal definidas. El 92.8% de la mortalidad por cáncer estaba bien certificada. Los errores predominantes fueron cánceres de sitio mal definido. Conclusiones: Los indicadores de calidad de certificación en Colombia mejoraron. Ante el buen comportamiento de los indicadores de calidad de la certificación de la muerte general y por cáncer, se considera que ésta es un insumo válido para la estimación de incidencia de cáncer.

Oncology services supply in Colombia / Servicios oncológicos en Colombia

Abstract Objective: To characterize the current status of oncological services supply in Colombia. Methods: A descriptive analysis of oncological services for cancer care in the adult and infant population that meet the requirements for operation according to the Special Register of Health Service Providers was carried out. The case - by - provider ratio was calculated based on the cancer incidence estimated for Colombia by the National Cancer Institute. Results: Were identified 1,780 qualified oncology health services in the country related to specialties for providing care to cancer patients. Twenty five providers nationwide had all three qualified services: chemotherapy, radiotherapy and surgery. Nearly 50% of the offer was concentrated in Bogotá, Antioquia and Valle del Cauca. Putumayo and the Amazonas group departments, with the exception of Vaupés, did not show any oncological services. Healthcare Providers were responsible for 87.8%, and independent professionals provided 12.2%. Outpatient services were 66.7% of oncology services, 17.4% was diagnostic support services and therapeutic complementation, and 15.9% was surgical services. 87.9% of the oncological service offer in Colombia takes place in the private sector. Conclusions: The ratio between the service groups is asymmetric, with few providers jointly offering the basic services for oncology treatment, which reflects how provision is fragmented. It is necessary to redefine the concept of oncology service under a comprehensive care approach and the importance of enabling functional units, comprehensive treatment centers and other forms of care.

Resumen Objetivo: Caracterizar la situación actual de la oferta de servicios oncológicos en Colombia. Métodos: Se realizó un análisis descriptivo de los servicios oncológicos para la atención de cáncer en población adulta e infantil, que cumplieron con los requisitos para su funcionamiento de acuerdo al Registro Especial de Prestadores de Servicios de Salud. La razón de casos por prestador se calculó a partir de la incidencia de cáncer estimada para Colombia por el Instituto Nacional de Cancerología. Resultados: Se identificaron 1,780 servicios de salud oncológicos habilitados en el país relacionados con especialidades para la atención de pacientes con cáncer. 25 prestadores a nivel nacional contaron con los tres servicios habilitados: quimioterapia, radioterapia y cirugía. Cerca del 50% de la oferta se concentró en Bogotá, Antioquia y Valle del Cauca. Los departamentos de Putumayo y del grupo Amazonas, con excepción de Vaupés, no registraron servicios oncológicos. El 87.8% fue ofertado por Instituciones Prestadoras de Salud y el 12.2% fue provisto por profesionales independientes. El 66.7% de los servicios oncológicos eran de consulta externa, el 17.4% eran servicios de apoyo diagnóstico y complementación terapéutica y el 15.9% servicios quirúrgicos. El 87.9% de la oferta de servicios oncológicos en Colombia está en el sector privado. Conclusiones: La relación entre los grupos de servicios es asimétrica, con pocos prestadores que ofertan de forma conjunta los servicios bases del tratamiento oncológico, lo cual refleja la fragmentación en la prestación. Es necesario redefinir el concepto de servicio oncológico bajo el enfoque de atención integral y la importancia de habilitar unidades funcionales, centros integrales de tratamiento y otras formas de atención.

Patterns and trends in cancer mortality in Colombia 1984-2008.

BACKGROUND: Cancer has become increasingly acknowledged as a public health issue in Colombia. Rates of the most common malignancies have been generally increasing. We update an evaluation of mortality trends in the major cancers in Colombia one decade ago, discussing the trends in the context of cancer control. METHODS: We calculated the annual age-standardized mortality rates for the major cancer sites by sex between 1984 and 2008; we also present the estimated annual percentage change (EAPC) for the entire period and for the last decade. RESULTS: There was an average of 32,000 cancer deaths annually in Colombia in the period studied. Overall cancer mortality rates decreased slightly in both men and women. The four most common sites of cancer death among men were stomach (17.6%), prostate (15.0%), lung (14.8%) and colorectum (6.5%). In women, the most common cancer sites were breast (12.3%), cervix (12.1%), stomach (11.5%) and lung (9.2%). Colorectal and CNS cancers exhibited the greatest increases (EAPC of 2.0% and 3.4% respectively) while the largest declines were seen for cancers of the larynx, stomach and oesophagus (EAPC between -3% and -4%). In the last decade, the greatest declines were seen in cervical cancer mortality rates (EAPC = -3.2). CONCLUSIONS: The slight decrease in mortality trends from all cancers combined is partially driven by the strong declines in mortality of stomach and cervical cancer. It may be still too early to properly evaluate trends in mortality due to other cancers and the relative impact of changing access to health care in Colombia.