Colorectal Cancer in Ukraine: Regional Disparities and National Trends in Incidence, Management, and Mortality

Statistical methods for measuring trends in colorectal cancer incidence in registries: A systematic review

Background

Monitoring cancer trends in a population is essential for tracking the disease’s burden, allocating resources, and informing public health policies. This review describes variations in commonly employed methods to estimate colorectal cancer (CRC) incidence trends.

Methods

We performed a systematic literature search in four databases to identify population-based studies reporting CRC incidence trends, published between January 2010 and May 2020. We extracted and described data on methods to estimate trends and assess model validity, and the software used.

Results

This review included 145 articles based on studies conducted in five continents. The majority (93%) presented visual summaries of trends combined with absolute, relative, or annual change estimates. Fourteen (10%) articles exclusively calculated the relative change in incidence over a given time interval, presented as the percentage of change in rates. Joinpoint regression analysis was the most commonly used method for assessing incidence trends (n= 65, 45%), providing estimates of the annual percentage change (APC) in rates. Nineteen (13%) studies performed Poisson regression and 18 (12%) linear regression analysis. Age-period-cohort modeling- a type of generalized linear models- was conducted in 18 (12%) studies. Thirty-nine (37%) of the studies modeling incidence trends (n=104, 72%) indicated the method used to evaluate model fitness. The joinpoint program (52%) was the statistical software most commonly used.

Conclusion

This review identified variation in the calculation of CRC incidence trends and inadequate reporting of model fit statistics. Our findings highlight the need for increasing clarity and transparency in reporting methods to facilitate interpretation, reproduction, and comparison with findings from previous studies.

Hospitalizations of Ukrainian Migrants and Refugees in Poland in the Time of the Russia-Ukraine Conflict

BACKGROUND

In the face of a sudden influx of several million migrants and war refugees from Ukraine to other European countries, knowledge about the health of Ukrainian citizens becomes increasingly important. The aim of the study is to identify the main health problems of hospitalized Ukrainian citizens residing in Poland in the period from 2014 to June 2022.

METHODS

This study is based on hospitalization data of Ukrainian patients in Poland taken from the Nationwide General Hospital Morbidity Study.

RESULTS

The study group covered 8591 hospitalization records. We observed two hospitalization peaks, one in patients aged 0-5 and the other one in those aged 20-35. After the official outbreak of the war, 2231 Ukrainian citizens were hospitalized in Poland. At this time, the most often reported principal reasons for the hospitalizations of adult women were diseases related to pregnancy, childbirth and the puerperium, whereas in groups of adult men diseases were related to injury, poisoning and certain other consequences of external causes, and in children and adolescents diseases were infectious and parasitic diseases.

CONCLUSIONS

Our findings may have implications for healthcare policies and service provision to newly arrived migrants and war refugees in target European countries.

Global Health 101

Global health is an evolving field that has been broadly defined as the promotion of health for all through transnational collaboration and research. It centers on the concepts of equity and collaboration. The focus of global health has recently undergone a major shift toward emphasizing the importance of a systems-based approach to healthcare delivery, which considers not only the target disease but also the many contextual factors, influencing the ability to deliver care equitably to a population to reduce the burden of any particular disease. Thus, an important global health delivery framework has been established to outline this inter- and multi-disciplinary systems-based to address major global health issues and improve health for all globally. The practice of global health, whether in research or in active intervention, necessitates guiding principles to ensure ethical conduct in the transnational partnerships and efforts to advance the field. With the introduction of the United Nations' Sustainable Development Goals in 2015, there has been a major shift in response to epidemiologic transition to focus on reducing the burden of noncommunicable diseases, including cancer, which disproportionately impact low-to-middle income countries. This is true for colorectal cancer, with care challenged by significant gaps in screening, early detection, and referral systems.

Colonoscopy Needs for Implementation of a Colorectal Cancer Screening Program in Ukraine

BACKGROUND

In Ukraine, there is no established colorectal cancer screening program. We aimed to project the number of screening colonoscopies needed for implementation of various CRC screening strategies in Ukraine.

METHODS

We modified a previously developed Markov microsimulation model to reflect the natural history of adenoma and CRC progression among average-risk 50-74-year-olds. We simulated colonoscopies needed for the following screening strategies: no screening, fecal occult blood test yearly, FOBT yearly with flexible sigmoidoscopy every 5 years, FS every 5 years, fecal immunohistochemistry test (FIT) yearly, or colonoscopy every 10 years. Assuming 80% screening adherence, we estimated colonoscopies required at 1 and 5 years depending on the implementation rate. In one-way sensitivity analyses, we varied implementation rate, screening adherence, sensitivity, and specificity.

RESULTS

Assuming an 80% screening adherence and complete implementation (100%), besides a no screening strategy, the fewest screening colonoscopies are needed with an FOBT program, requiring on average 6,600 and 26,800 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. The most screening colonoscopies are required with a colonoscopy program, requiring on average 76,600 and 101,000 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. In sensitivity analyses, the biggest driver of number of colonoscopies needed was screening adherence.

CONCLUSIONS

The number of colonoscopies needed and therefore the potential strain on the healthcare system vary substantially by screening test. These findings can provide valuable information for stakeholders on equipment needs when implementing a national screening program in Ukraine.

Barriers to Evidence-Based Colorectal Cancer Care in Ukraine

BACKGROUND

The incidence of colorectal cancer (CRC) is increasing in many low- to middle-income countries, including Ukraine. Ukraine reports high mortality rates in CRC patients. To identify potential areas for targeted interventions to improve CRC care in Ukraine, we investigated Ukrainian clinician perspectives on evidence-based CRC treatment guidelines.

METHODS

An explanatory sequential mixed-methods study design was used. A survey was administered to attendees of a regional surgical conference. Semi-structured interviews were subsequently performed with practicing clinicians in Ukraine. Interviews were coded to identify prominent themes.

RESULTS

Quantitative: 105 clinicians completed the survey. 76% of respondents reported using guidelines in daily practice. Lack of English proficiency was cited by 28.6% of respondents as a barrier to guideline use. Improved knowledge and additional financial resources were reported as factors that would be helpful in providing evidence-based care.

QUANTITATIVE

15 clinicians were interviewed. Two major themes were identified: limitations in access to the medical literature resources (language barriers and financial barriers), and sense of clinician initiative and willingness to learn despite hardships.

CONCLUSIONS

Clinicians in Ukraine have positive perspectives on utilization of evidence-based CRC treatment guidelines. However, they face major barriers in accessing resources needed to keep up-to-date on the current literature. Fortunately, there exists both willingness and initiative on the clinician level to pursue continuing education. Efforts should be made on the international society level to improve open-access and foreign language translation availability to support physicians in Ukraine and other low- to middle-income countries.

The Current Landscape of Staging and Treatment of Colorectal Cancer in a Region of Ukraine: a Mixed Methods Study

BACKGROUND

In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates.

METHODS

An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached.

RESULTS

A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care.

CONCLUSION

In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients.

Trends in Solid Tumor Incidence in Ukraine 30 Years After Chernobyl

PURPOSE

There is limited knowledge of the long-term health effects of the Chernobyl nuclear power plant accident that occurred more than 30 years ago in Ukraine. This study describes trends in the incidence of solid organ malignancy in Ukraine and the five regions most affected by the radioactive fallout.

METHODS

The National Cancer Registry of Ukraine was queried for age-standardized incidence rates (ASIRs) of solid organ malignancy in Ukraine and the regions of Kyiv, Chernihiv, Zhytomyr, Rivne, and Volyn covering the period of 1999 to 2016. Joinpoint analysis was used to calculate the average annual percentage of change.

RESULTS

The highest burdens of cancer incidence in Ukraine were seen in the lung, stomach, breast, and prostate. We observed significant increases in the ASIRs of colon (average annual percentage of change, 1.5 [95% CI, 1.3 to 1.7]), rectal (0.9 [95% CI, 0.6 to 1.2]), kidney (2.3 [95% CI, 1.8 to 2.9]), thyroid (4.2 [95% CI, 3.1 to 5.3]), breast (1 [95% CI, 0.6 to 1.4]), cervical (0.7 [95% CI, 0.3 to 1.2]), and prostate (3.9 [95% CI, 3.6 to 4.2]) cancers, with decreases in stomach (−2.4 [95% CI, −2.5 to −2.3]) and lung (−1.8 [95% CI, −2.1 to −1.5]) cancers. ASIRs in the affected regions were similar to nationwide rates, with the exception of those for Kyiv.

CONCLUSION

The incidence rates of many solid organ malignancies in Ukraine are rising. However, the rates of solid organ malignancy in the five regions most affected by fallout did not substantially differ from national patterns, with the exception of those for Kyiv. Ongoing monitoring of cancer incidence in Ukraine is necessary to understand how best to decrease disease burden nationwide and to elucidate the causes of regional variations in ASIRs, such as access to diagnostics and environmental exposures.