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Revista colombiana de Gastroenterología

versión impresa ISSN 0120-9957

Rev Col Gastroenterol vol.32 no.4 Bogotá oct./dic. 2017

https://doi.org/10.22516/25007440.175 

Original articles

Disease Burden of Gastric Cancer in Disability-Adjusted Life Years in Colombia

Juan José Triana1 

Juan Diego Aristizábal-Mayor1 

María Camila Plata1 

Mauricio Medina1 

Laura Baquero1 

Sebastián Gil-Tamayo1 

Ana María Leguizamón1 

Felice Leonardi2 

Camilo Castañeda-Cardona3 

Diego Rosselli4 

1Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.

2Eli Lilly Colombia, Bogotá, Colombia.

3Neuroeconomix, Bogotá, Colombia.

4Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia. Correo electrónico: diego.rosselli@gmail.com


Abstract

Objective:

Gastric cancer is the second most common cause of cancer death and the fifth most common neoplasm in the world. In Colombia, it is the leading cause of cancer mortality. The annual incidence and mortality are 16.3/100,000 and 14.2/100,000 inhabitants respectively. The aim of this study was to estimate the disease burden in Colombia as measured in disability-adjusted life years (DALYs).

Methods:

This study focuses on prevalence in 2014. To estimate prevalence, a search was made in the registries of the Social Protection Information System (SISPRO) and the National Administrative Department of Statistics (DANE). The average duration of cases and estimated survival were obtained from the local literature. DALYs were calculated by adding the years of life lost due to premature death (YLLs) and years of life lived with disability (YLD) according to the methodology of the World Health Organization (WHO).

Results:

Prevalences estimated for five years in the population older than 15 years were 40.9/100,000 for women and 62.5/100,000 for men. The total DALY was 293,418, with a rate of 623/100,000 inhabitants; 97.4% correspond to YLL. The YLD and YLL for Colombia were 16/100,000 and 607/100,000, respectively.

Conclusions:

Data obtained from SISPRO and DANE estimate a high disease burden in Colombia. It is necessary to implement early cancer detection strategies to reduce the burden of disease and improve patient prognosis.

Keywords: Gastric neoplasms; cost of illness; prevalence; factual databases

Resumen

Objetivo:

El cáncer gástrico es la segunda causa de muerte por cáncer y la quinta neoplasia más frecuente en el mundo. En Colombia, es la primera causa de mortalidad por cáncer. La incidencia y mortalidad anuales son 16,3 y 14,2/100 000 habitantes, respectivamente. El objetivo de este estudio fue estimar su carga de enfermedad, medida en años de vida ajustados por discapacidad (AVAD), en Colombia.

Métodos:

Se desarrolló un estudio con enfoque en prevalencia para el año 2014. Para estimar la prevalencia, se realizó una búsqueda en los registros del Sistema de Información en Protección Social (SISPRO) y el Departamento Administrativo Nacional de Estadística (DANE). La duración promedio de los casos prevalentes y la sobrevida estimada se obtuvieron de la literatura local. Los AVAD fueron calculados sumando los años de vida perdidos por muerte prematura (AVPM) y los años de vida vividos con discapacidad (AVVD), según la metodología de la Organización Mundial de la Salud (OMS).

Resultados:

Las prevalencias estimadas para 5 años en población mayor de 15 años fueron 40,9/100 000 en mujeres y 62,5/100 000 en hombres. El total de AVAD fue 293,418, con una tasa de 623/100 000 habitantes, de los cuales el 97,4% corresponde a AVPM. La tasa de AVVD y AVPM para Colombia fue 16 y 607/100 000, respectivamente.

Conclusiones:

Los datos obtenidos de SISPRO y el DANE estiman una alta carga de enfermedad en Colombia. Es necesaria la implementación de estrategias de detección temprana del cáncer para disminuir la carga de la enfermedad y mejorar el pronóstico de los pacientes.

Palabras clave: Neoplasias gástricas; costo de enfermedad; prevalencia; bases de datos factuales

Introduction

Gastric cancer causes a considerable global burden: it is the second cause of cancer death in the world after lung cancer and the fifth most frequent neoplasm for both sexes. 1,2

The disease’s epidemiology varies considerably by region and sex, due to the difference in dietary habits, age and other risk factors of the population 3. The regions with the highest incidence are Asia and Eastern Europe, followed by South America. In North America and South Africa the incidence is lower. 3 Generally, the 5 year survival rate is less than 20%. 4 Late diagnosis of gastric cancer is due in large part to nonspecific initial symptoms. However, in Japan and Korea survival has increased to 90% due to early diagnosis and endoscopic resection of lesions. 1,4

In Colombia, gastric cancer is the leading cause of cancer death. It has an annual incidence of 16.3/100 000 inhabitants and a calculated mortality of 14.2/100 000 inhabitants. 5 According to Colombian literature, 41% of the patients are in stage III at the time of diagnosis while 21% are in stage IV according to the criteria of the American Joint Committee on Cancer (AJCC). 6 According to an observational study of 1,039 patients with gastric cancer, survival is lower than that reported worldwide, and a 5-year survival rate of 11% has been calculated. 7

The disease burden attributable to cancer is 7.8% of the total DALYs worldwide within which gastric cancer contributes 0.7% of the total DALYs. 8,9 In Brazil, a cancer disease burden study has estimated that of the total DALYs caused by cancer, 95.4% corresponded to YLL. 10 This figure is considerably higher than that registered in developed countries, where YLL are around 80% for cancer, in general. This shows the relevance of disease burden of gastric cancer and the needs for early diagnoses and development of programs for early detection of the disease. 10

The objective of this study was to use Colombian prevalence data and the methodology established by WHO to estimate the country’s disease burden from gastric cancer measured in DALYs. 11,12,13

Materials and methods

The study used data on the prevalence of gastric cancer in Colombia for 2014. To estimate the prevalence of gastric cancer in Colombia, a search was made of the SISPRO records. The main source of SISPRO is the Individual Registry of Health Services Provision (RIPS), which centralizes all data related to individual health care in Colombia and which is managed by the Ministry of Health and Social Protection.

Five years of RIPS’ data, from 2010 to 2014, for International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) which is related to gastric cancer from C160 to C166 and which includes C169 (malignant tumors of the cardia, gastric fundus, stomach body, pyloric antrum, pylorus, minor curvature and greater curvature of the stomach, and malignant tumor of the stomach, unspecified part) were used for this study. These diagnoses were scrutinized with two diagnostic filters: confirmed new and confirmed repeated cases excluding the type of diagnosis, diagnostic impression and unspecified.

In order to quantify the number of patients with this diagnosis, the function “people served” was used, which includes each person only once even if that person has been attended more than once during the 5 years. After obtaining these data, they were classified according to sex, age group (by five-year periods) and geographic location by department.

To estimate the prevalence of gastric cancer in 2014, the DANE information was used as a population denominator, grouping the population by five-year periods, estimated for the year in question.

The DANE data are based on the population census conducted in 2005 in Colombia (www.dane.gov.co) and its projections, although there is evidence that it may underestimate the older population. 14,15 Prevalence was estimated by sex and by age group in the same way as the general prevalence, using the population estimate according to the DANE for these subgroups as the denominator.

Estimation of dalys

DALYs were calculated from the sum of the YLL and the years lived with disability (YLD) according to the WHO methodology proposed in 2013.11,12 This method allows YLL to consider the mortality attributable to a disease while YLD considers the morbidity attributable to that disease. An expectation of life at birth of 86 years was used for men and women, and life expectancies for each five year age range were used, so that, for example, the life expectation used for the 75 to 79 year age group was 12.9 years while that used for those 80 and over was 9.3 years. No age adjustments were made. 11 Although other studies of disease burden use the real life expectancy for each country, 16 the WHO recommends standardization to allow international comparisons.

Although the new methodology has opened up a debate about whether incidence or prevalence should be used for calculation of DALYs, researchers have adopted the approach based on prevalence to allow calculation of YLD in the surviving population with chronic outcomes. The disability weights (on a scale between 0 and 1, where 0 is perfect health) for health statuses secondary to gastric cancer were based on the studies of Salomon et al. and Murray et al. 8,11 The use of prevalence rather than incidence causes an increase in total DALYs for all causes. 12

The YLD estimation was based on the estimated prevalence with different disability weights for gastric cancer according to the Murray methodology. The proportion of patients estimated to be in each of the four health statuses from oligosymptomatic to terminal was obtained from a study conducted from 2004 to 2008 in Colombia and from an expert panel of gastroenterologists with experience in the management of patients with gastric cancer. 6 The YLD were categorized according to the following age groups: 0-4 years, 5-14 years, 15-29 years, 30-44 years, 45-59 years, 60-69 years, 70-79 years and 80 years or more. Since this study is based on prevalence, the average duration of the disease was not included in the YLD calculation.

The YLL were calculated on the basis of the differences between the ages of death of patients and the life expectancies proposed by the WHO (86 years for men and women) and on prevalences obtained from RIPS and DANE. No weighting was used. The information was organized into the same age ranges.

Data analysis

All data obtained from all sources (RIPS, DANE and literature) were organized into Excel® spreadsheets for analysis and calculation of five-year prevalences of gastric cancer, survival, average gastric cancer patient survival times in years and annual case-fatality rates. Subsequently, the WHO template for calculation of disease burden was used to obtain DALYs. 13

Results

The data consulted from RIPS for 2010 to 2014 showed that 15,972 patients with confirmed diagnoses of gastric cancer were treated in Colombia: 9,467 men (59.3%) and 6,495 women (40.7%), see Table 1. According to these data, the estimated prevalences in the over-15-year old population for those five years were 40.9/100,000 women and 62.5/100,000 men, see Table 2.

Table 1 Number of patients treated whose primary diagnosis was gastric cancer from 2010 to 2014 by age groups. RIPS data 

* The Overall Total column shows the total number of people served at some point in the period, not necessarily the amount of people served per year.

Table 2 Prevalence for 5 year age-periods between 2010 and 2014 for gastric cancer in men and women, using primary diagnoses 

* The Overall Total column does not correspond to the sums of the other columns but rather to the number of people treated at some point in the five-year period. Prevalence is calculated by using the average population of the period as the denominator.

The four five-year periods from 55 years of age to 74 years of age showed significant numbers of patients beyond the overall total treated. Since number of times patients were seen or treated during the years 2010 to 2014 was 96,805, it can be estimated that, on average, each patient was seen or treated six times.

The total number of deaths obtained indicated by the mortality rate was 10,797. These data were classified into five-year periods and grouped into eight age groups: 0-4 years, 5-14 years, 15-29 years, 30-44 years, 45-59 years, 60-69 years, 70-79 years and 80 years or more. Of the total deaths, 3,057 occurred in 2014. The total YLL (81,069) and the YLL per 100,000 inhabitants (170.1) were calculated on the basis of these data.

The total YLD was calculated from cases determined for each age group and the average survival time for the disease reported in Colombian literature (21 months). 7 Four health statuses for gastric cancer were used to calculate YLD: diagnosis and primary therapy (disability weight of 0.294), metastatic stage (disability weight of 0.484), terminal stage (weight of disability of 0.508) and controlled phase (disability weight of 0.031). 8,11 The analysis of the panel of experts and reports in the literature were used to establish the percentage of the average survival time hypothetically remaining for patients in each health status. Applying 15% for diagnosis and primary therapy, 30% for metastatic stage, 15% for terminal stage and 40% for controlled phase, a disability weight of 0.278 was calculated for the time lived with gastric cancer.

The total DALY was 82,326, with a rate of 172.7/100 000 inhabitants, 98.5% of which corresponds to YLL (Table 3). The rate of YLD for the Colombian population was 2.6/100,000 inhabitants. The age group with the most DALYs, 45-59 years old, accounts for 38.7% of the total. It is followed by the 60-69 year group.

Table 3 Distribution of DALYs, YLL and YLD due to gastric cancer in Colombia, according to five-year periods, for the year 2013. Rates per 100,000 inhabitants 

Discussion

Although gastric cancer is first among cancers as a cause of death in Colombia, 2 it has received less attention than cervical cancer, breast cancer and prostate cancer. In terms of incidence, it is the first among men, followed by prostate cancer; while among women it occupies fourth place after breast, cervical and colorectal cancer. 2 According to these figures, its age-adjusted incidence is 26.5/100,000 person-years for men and 15.4/100,000 person-years for women. 17 According to data from the National Cancer Institute, Colombia is considered to be a country with a high incidence and mortality rate due to gastric cancer.

The data obtained from SISPRO were originally collected by the Ministry of Health and Social Protection of Colombia. However, the registration of RIPS is subject completion of diagnoses by doctors and placed in medical records according to the ICD-10. It is sensible to assume that some of these records have not been recorded optimally, and it is especially like that they have been subject to underreporting. The implication is that this database contains errors. Previous studies from our group have suggested that the diagnostic accuracy of RIPS improves for diseases like multiple sclerosis that are diagnosed by a selected group of specialists and whose treatment requires the allocation of important resources by the health care system. 18

Taking possible underreporting in the RIPS into account, this study found a higher prevalence of gastric cancer than that predicted by the 2012 Globocan initiative for Colombia of 20.6 for women and 37.5 for men, but our finding was similar to the one provided by the International Agency for Research in Cancer (IARC) of the WHO which estimates the prevalence and incidence for Colombia based on data from a surveillance system that covers less than 10% of the population.2,14,19 Although these data were the best available for Colombia, they only come from regional records taken from four cities: Cali, Pasto, Manizales and Bucaramanga. 20-23

It is important to note the a preliminary analysis of figures reported by DANE on showed 23,253 deaths directly caused by gastric cancer in Colombia from 2010 to 2014. This exceeds the total number of reported cases in the RIPS. 24 These official figures are of significant value as an objective reference for the number of patients with gastric cancer at the time of death and reinforce the need to improve cancer surveillance systems at the national level.

DANE projections for 2014, based on the 2005 census, were used to calculate DALYs in Colombia because there were the most reliable projections that were available for the whole country. The most important great majority DALYs were calculated on the basis of YLL due to lethal nature of this disease for which only one out of nine patients survives for five years after diagnosis. 7 A good comparison for the results of our study is found in regional studies from Chile, a country with an epidemiological behavior similar to that of Colombia, which showed that 9.6% of these patients survived for five years. 25 These numbers are also comparable to the 11% found in the de Vries study in Bucaramanga. 7 In developing countries, total DALYs are more than 90% dependent on YLL. In contrast, in developed countries, the proportion is close to 80%. 10

The gastric cancer disease burden reported in the literature for Colombia is lower than those of other countries with similar incidences. Although Colombia is one of the countries with the highest incidences of gastric cancer in the world, the reported DALY rate of 304/100,000 inhabitants is similar to that of countries with intermediate incidences. 9 Countries such as South Korea and Japan with high incidences but strict screening programs and early cures of gastric cancer, and where the proportion of YLL in DALYs is lower than in Colombia, have rates that are much higher than those of Colombia where diagnosis is late and there are more premature deaths among young adults. 26. Although the mortality data obtained by our study from the SISPRO and DANE databases estimate a higher disease burden, they may still be underestimating the true magnitude of the problem. 27

In conclusion, Colombia has a significant incidence of gastric cancer that indicates a need for more work in areas such as proper registration since, as this study shows, more deaths from this disease are reported than the reported number of consultations per patient in the health system for this disease. Other relevant issues linked to the evaluation of this study’s data which require greater emphasis include screening, early diagnosis, periodic monitoring of the evolution of the disease and timely treatment in order to reduce the disease burden and thus improve the prognoses of patients.

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Received: April 04, 2017; Accepted: October 06, 2017

Conflict of Interest

This work received financial support from Eli Lilly Interamerica, Colombia

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