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DOI 10.1007/s10198-009-0195-9
ORIGINAL PAPER
JEL Classification
Introduction
Cancer was the second leading cause of death in Russia in
20062007, with colorectal cancer (CRC) accounting for 13%
of these deaths. The mean age of patients who died from
malignant neoplasms was 65.6 years, with 12.5% dying within
employed ages. Its significance in population health appears
underestimated, reflected by the lack of a national screening
programme and by the limited access to innovative drugs and
treatment. This report addresses three important issues concerning CRC in Russia: (1) the CRC burden, including discussion on data sources and quality of available data, (2)
screening for CRC and, (3) medical care for patients with CRC.
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M. Avksentyeva
Table 1 Age-standardized colorectal cancer incidence (I) and mortality (M) in Russia, per 100,000 [1]
Year
Colon cancer
Rectal cancer
Men
I
Women
M
Men
M
Women
M
1997
12.25
9.2
10.28
7.02
11.54
8.65
7.64
5.25
1998
12.83
9.37
10.36
7.1
12.02
8.67
7.74
5.29
1999
2000
12.65
12.95
9.23
9.26
10.65
10.81
7.05
7.16
11.97
12.43
9.22
9.55
8.02
8.14
5.7
5.7
2001
13.05
9.29
11.13
7.21
12.37
9.46
8.08
5.62
2002
13.52
9.47
10.94
7.08
13.11
9.5
8.32
5.55
2003
13.93
9.67
11.51
7.38
13.00
9.75
8.27
5.46
2004
14.35
10.02
11.72
7.3
13.23
9.56
8.27
5.48
2005
14.45
9.88
11.98
7.33
13.76
9.64
8.47
5.43
2006
14.74
12.04
7.37
13.82
9.37
8.46
5.37
2007
14.96
9.91
12.20
7.37
13.89
9.58
8.55
?22.49
?10.29
?20.01
?5.27
?20.73
?9.17
?10.86
-2.86a
?2.05
?0.98
?1.84
?0.52
?1.90
?0.88
?1.04
-0.29a
Growth [%]
Average annual growth rate [%]
a
10.1
5.11
In men, colon and rectal cancers are the fifth and sixth
causes of cancer deaths, accounting for 5.6% and 5.2% of
cancer deaths, respectively. In women, colon cancer is the
third cause of cancer mortality (9.1%), while rectal cancer
is fifth (6.5%). Taken together, they place CRC as the
second cause of cancer death for women (after breast) and
the third for men (after lung and stomach).
Median age of diagnosis for rectal and colon cancer was
66.9 and 68.3 years in 2007. Median age of death was 69.6
and 70.8 years, respectively.
Prevalence for both colon and rectal cancer has increased
between 1997 and 2007: from 51.8 to 75.4 for rectal cancer
and from 55.6 to 92.9 for colon cancer (per 100,000).
There is an extremely high first-year death rate of most
cancers in Russia, including CRC. This indicator has
slightly decreased in the last 10 years but is still high: in
2007, 30.0% and 34.4% of patients with newly diagnosed
rectal and colon cancer died in the first year after diagnosis
compared to 36.5% and 42.1% in 1997. However, in 2007,
48.2% and 47.5% of rectal and colon cancer patients were
followed up at medical institutions for 5 years and more
(this measure can be considered as a rough estimation for
CRC 5-year survival).
Cancer registries and data sources
The system of collecting cancer data (registration of incidence) was launched in 1939 in cities with oncology
institutions, and in 1953 in all cities and rural areas in the
USSR. First reports about cancer epidemiology in the
USSR were presented even earlier at oncology congresses
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Register and to the N.N. Blokhin Russian Oncology Scientific Centre. The computer database at the Gertzen
Institute includes incidence (from 1980 onwards), prevalence, mortality (from 1989 onwards), percentage of
patients that died in the first year after diagnosis, percentage of patients that are still registered at oncology dispensary 5 years after diagnosis (known to be alive), stage
at diagnosis and some treatment details (for patients with a
likelihood of remission or eligible for curative treatment,
not for patients receiving palliative care). Cancer data are
presented separately for adults and children, and annual
reports have been published since 1993.
Annual reports of the Ministry of Health and Social
Care, Federal Statistical Service and P.A. Gertzen Research
Oncology Institute are published, but the number of copies
is limited and not all reports can be found in libraries. The
report of the Ministry of Health is on the internet, in
commercial databases of normative documents, but does
not contain all data; moreover, the structure of data presentation in the reports by the Ministry of Health differs
each year (for example not all types of cancer are analysed
each year, some reports present crude rates while others
age-standardized rates) so it is difficult to analyse trends or
compare time series. Furthermore, not all collected data are
analysed and included in the reports.
Data presented by federal research institutes usually do
not differ. However, several publications mention the
problems with collecting and analysing cancer data in Russia
due to misrepresentation. For instance, the Ministry of
Health and Social Care acknowledges that false registration
of the disease stage takes place, reflected by the unlikely
mortality rate of Stage I patients in the first 3 months in some
regions [3]. Other examples include abnormally low rates of
death due to complications despite high surgery rates,
postmortem diagnosis of cancer made without autopsy, high
5-year survival rates, in cancers known to have very low
survival rates, as well as discrepancies in table data [4].
CRC screening
There are no typical screening programmes in Russia;
instead, a preventive mass medical examination programme
occurs which is not aimed at the early detection of certain
diseases (particularly cancer), but includes examinations by
several specialists to assess individual health status.
Preventive mass medical examination was first launched
in 1986 in the USSR, but had many problems because no
targeted financing was provided, physicians had to do extra
work without any incentive and the population was not
interested in participating. Formal analysis of the programme has never been performed. Some publications
suggest that the programme failed because of disinterest by
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medical specialists, absence of concrete objectives, insufficient equipment, low level of professional skills among
primary care specialists and lack of continuity of care. In
1987, in spite of this mass population examination, 21.4%
of malignant neoplasms were detected in Stage IV and
28.2% in Stage III [5].
The programme stopped after the break-up of USSR, but
was restored in Russia in 2006. Nowadays, it is aimed at
preventive medical examination of certain population
groups: initially state and municipal institutions employees
and those exposed to professional hazards, subsequently
extended to all the employed population in 2008. The
programme includes: mammography (for women older
than 40 years once every 2 years), ECG, blood test, urinary
test, blood cholesterol and glucose, fluorography (once
every 2 years), PSA (for men older than 40 years), CA-125
(for women older than 40 years) and examination by a
number of specialists (therapist, endocrinologist, ophthalmologist, neurologist, surgeon, urologist or gynaecologist).
Ultrasound prostate examination is also included despite its
limitation in evidence-based diagnosis for prostate cancer.
The average cost of the programme was planned to be 500,
540, 974 and 1042 roubles per patient in 2006, 2007, 2008
and 2009, respectively, ( 14.63, 15.56, 27.11 and
25.141). The programme has not included any CRC
screening test. The Russian Society of Evidence-Based
Medicine Specialists criticized the contents of the programme and proposed including the pap smear and faecal
occult blood test (FOBT) [6]; the former was included in
2009, the latter was not, for unknown reasons.
Since 1948, there have been a number of legal decrees
from the Ministry of Health (in both the USSR and postSoviet Russia) enforcing different cancer detection examinations. Prevention was declared a priority in Soviet health
care and many activities proposed for early diagnosis,
especially cancer (i.e. mammography, pap smear, fluorography, surveillance of high-risk groups such as cervical
erosion, gastric ulcer, antacid gastritis, intestinal and gastric polyposis). However, implementation has always been
difficult for the aforementioned reasons, including lack of
incentive for providers and participants, absence of concrete objectives, insufficient equipment, low level of professional skills among primary care specialists and lack of
continuity of care.
The official statistics shows that few cancers in general and
colorectal cancer in particular are detected early (see Table 2).
There are limited data regarding time to diagnosis and
medical errors. Multiple sources systematically underline
the necessity for implementing a screening programme
with the use of the FOBT and colonoscopy. Many
1
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Table 2 CRC detection in
Russia [14]
M. Avksentyeva
Year
Colon cancer
Rectal cancer
Colon cancer
Rectal cancer
1997
1.5
5.4
32.5
29.1
1998
1.5
5.8
31.8
28.6
1999
2000
1.6
1.6
6.2
6.1
32.4
31.3
28.4
27.8
2001
1.8
7.2
31.1
27.2
2002
2.2
8.3
30.5
26.7
2003
2.2
7.4
30.0
26.0
2004
3.1
8.6
29.5
26.5
2005
3.2
8.5
29.7
24.6
2006
2.5
8.2
29.7
26.3
2007
3.0
7.7
28.9
25.6
specialists still emphasize out-dated digital rectal examination in general practice. Still no formal screening programme exists at present with no explanation for the
rationale. We can suppose that underestimation of the
problem by decision makers and population, lack of
equipment and qualified specialists who perform colonoscopy, the low willingness of the population to undergo the
discomfort of an examination may play a role in the
absence of CRC screening in Russia.
Roubles, bill.
Euro, bill.
2007
897.3
25.9
2006
690.7
20.2
2005
559.5
14.8
2004
435.2
11.7
2003
355.6
10.7
2002
311.0
11.7
2001
238.4
9.1
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2002
2003
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2005
2006
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substances. These programmes do not cover routine treatment (medication, radiation therapy or surgery).
Resources for routine oncology care are allocated
annually at a federal and regional levels. Oncology institutions are financed mostly regionally, but there are several
federal institutions financed federally, including advanced
oncology centres supplying expensive and complex treatment. There is no free access to routine oncology care
spending. It is known that many oncology institutions are
situated in old buildings that need repair. There is lack of
equipment, and access to modern treatment is limited.
There are a few data on some cancer treatments in
official statistical databases and the number of patients
receiving different treatments is monitored. For rectal
cancer in 2007, 59.7% of patients who completed special
treatment had surgery only, 37.7% had surgery plus other
treatment, 1.9% had radiotherapy only, 0.1% had chemotherapy only, while the remainder received combined
chemo- and radiotherapy. There are no data about colon
cancer treatments, while laparoscopic CRC surgery is
rarely available.
The need for screening, high-risk group surveillance
(including polypectomy) and modern combined treatment
for CRC is systematically underlined by leading Russian
specialists, but there is little evidence of common practice.
We may suppose that limited access to updated information
about best practice, together with financial deficiency,
significantly impairs quality of care.
All leading oncologists consider a national oncology
programme to be necessary, despite its omission in the
2006 and 2007 National Health Projects. In 2009 the
Ministry of Health announced the launch of a national
oncology programme planned for 20092015, with the
proposed federal financing of 28 bill. roubles ( 675.7
mill.) for 20092012 [9]. On the whole, the programme is
aimed at early cancer detection with the goal of decreasing
cancer mortality and disability. Specific objectives include
population education, mass screening, improved posttreatment surveillance, development of epidemiological
surveillance and implementation of standards of care [10].
Eleven regions of Russia will be included in the programme in 2009, with subsequent national expansion.
These 11 regions were chosen on the basis of several criteria concerning mostly the material and technical basis of
oncology institutions, qualification of personnel and
availability of space to install new equipment. At the
moment, subsidies for purchasing equipment have been
approved for only these 11 regions [11], while routine care
has not been covered.
In 2005006 federal standards of medical care for CRC
patients were approved by the Ministry of Health and
Social Development. These standards include lists of
medical diagnostic and treatment procedures, percentage of
M. Avksentyeva
2007 (9 months)
Fig. 1 Sales of drugs used for CRC treatment, thousands USD (IMS
Health, RMBC database)
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Conclusion
CRC is a serious and underestimated problem of population
health in Russia. CRC incidence and mortality seem less
than they are in reality because of the separate registration
of colon and rectal cancer. If counted together, CRC would
be the second cause of cancer death for women (after breast)
and the third for men (after lung and stomach).
About a quarter of all new CRC cases are diagnosed at
Stage IV and one-third of patients with newly diagnosed
CRC die in the first year after diagnosis. Screening for
CRC is still not included in the national programme of
preventive medical examination.
There are no data on CRC treatment effectiveness and
access to innovative treatment in common practice. New
drugs for CRC treatment are included in the documents that
regulate access to care, i.e. drug lists and standards of care,
but interviews with cancer patients showed that many of
them are not included in any reimbursement programme
and have to pay for the drugs, and there are problems with
drug supply even for patients who are entitled for reimbursement. A national programme for oncology care
development was launched in 2009, but it does not cover
routine treatment.
Conflict of interest statement The author does not report any
conflict of interest associated with this paper.
References
1. Chissov, V.I., Starinsky, V.V., Petrova, G.V.: Malignancies in RF
in 2007 (morbidity and mortality) (Translated from Russian:
Zlokachestvennye novoobrazovanija v Rossii v 2007 godu
(zabolevarmost i smertnost)). Moscow (2008)
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2. Merkov, A.M.: Population health and methods of its analysis.
Selected works (Translated from Russian: Zdorovje naselenija i
metody ego isuchenija. Izbrannyje proizvedenija). Bednyj MS
(ed). Statistica, Moscow (1979)
3. Annual Report of the Ministry of Health and Social Care and
Russian Academy of Medical Sciences about the health state of
Russian population in 2006 (Translated from Russian: Gosudarstvenniy doklad o sostojanii zdorovja naselenija Rossijskoj
Federatsii v 2006 godu). http://www.consultant.ru/online
4. Kharchenko, N.V., Petrova, G.V., Gretsova, O.P.: Assessment of
quality of the reporting documents received from regional
oncological dispensaries by forms 7 and 35 (Translated from
Russian: Otsenka kachestva otchyotnoj documentatsii territorialnyh oncologicheskih dispanserov po formam 7 i 35).
http://vestnik.mednet.ru/content/view/39/30/
5. Health care in Russia: XX century (Translated from Russian:
Zdravookhranenije Rossii. XX vek). GEOTAR-MED, Moscow
(2001)
6. Danishevsky, K.: How well the strategy of the Ministry of Health
and Social Development proposed in the document Mass health
examination of the working population in 20082009 is reasoned? Primary analysis of the pros and cons (Translated from
Russian Naskolko produmana srategija Minzdravsotsrazvitija
izlozhennaja v dokumentakh O provedenii v 20082009 godah
dopolnitelnoj distanserizatsii rabotajushego naselenija. Pervichnyj analiz za I protiv). http://www.osdm.org/modules.php?
name=Smi&op=page&folder=8&contentsite=37.htm
7. Public Spending in Russia for Health Care: issues and options.
Public expenditure review of the World Bank. http://www-wds.
worldbank.org/
8. The report about the State Program of Free Medical Care Guarantees implementation in 2007 (Translated from Russian Doklad
o khode realizatsii Programmy gosudarstvennykh garantij okazanija grazhdanam Rossijskoj Federatsii besplatnoj meditsinskoj
pomoshi v 2007 godu). http://www.minzdravsoc.ru/docs/mzsr/
letters/112
9. Statement of the Minister of Health and Social Development T.
Golikova on Sept 15, 2008. http://www.minzdravsoc.ru/health/
disease/2
10. Presentation of The Director of the Department of Health care
organization and development of Ministry of Health and Social
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M. Avksentyeva
11.
12.
13.
14.
15.
16.
Further reading
The report about the State Program of Free Medical Care Guarantees
implementation in 2006 (Translated from Russian: Doklad o
khode realizatsii Programmy gosudarstvennykh garantij
okazanija grazhdanam Rossijskoj Federatsii besplatnoj meditsinskoj pomoshi v 2006 godu). http://mzsrrf.ru/inf_cur/815.html
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