UNIVERSITY OF MEDICINE AND PHARMACY CRAIOVA EPIDEMIOLOGY OF BREAST CANCER AND CERVICAL CANCER IN THE COUNTIES OF OLTENIA 1984-2006 ABSTRACT PhD student DRAGOMIR IULIANA MANUELA SCIENTIFIC COORDONATOR PROF. DR. FLORINEL BADULESCU CRAIOVA 2010 1
CONTENTS GENERAL PART CHAPTER I INTRODUCTION CHAPTER II CANCER EPIDEMIOLOGY General concepts of epidemiology Methods of conducting epidemiological studies Statistical and epidemiological concepts Analysis of epidemiological studies CHAPTER III REGISTER OF CANCER CHAPTER IV Cervix cancer and cancer breast epidemiology SPECIAL SECTION CHAPTER PURPOSE OF THE STUDY CHAPTER VI MATERIAL AND METHODS CHAPTER VII RESULTS CHAPTER VIII DISCUSSIONS CHAPTER IX CONCLUSIONS BIBLIOGRAPHY Key words: Cancer epidemiology, breast cancer, cervix cancer, incidence, prevalence, mortality. INTRODUCTION In the recent decades in Romania breast cancer and female genital cancers, particularly cervical cancer represent the essential problems for public health by capturing the attention of medical professionals and healthcare decision makers. Specific indicators of mortality, incidence, prevalence and belated diagnosis and the high costs for these affections are the defining elements that emphasize the importance of such affections. In Romania, there are annually of 60,000 new cancer cases. The total cases of death from cancer was of 45,676 in 2006 in Romania and represented 17, 5% of all deaths, being the second leading cause of death after cardio-vascular system. Romania records a growing of the number of cancer cases, especially for those two locations mentioned above unlike most of the Western European countries where in the recent years has been a reversal of the trend, namely a decrease in the number of new cases due of the effectiveness of screening and detection programs. The second most common female cancer worldwide is cervical cancer. In the world over half a million women are annually diagnosed with this disease. In 2008 there were estimated 275,000 deaths worldwide which have accounted 9% of deaths raised by the cancer in women. In Europe there are 30 000 deaths every year, and in Romania in 2006 there were 1829 such cases. In Romania, the screening programs have been sporadic and limited in time or territory, the late diagnosis is added to this, increasing of the diagnosis quality and respectively the access to medical services, thus registering an increase of new cases of disease. This 2
continuous increase from year to year can be explained by the demographic profile of the population at risk. The two studied cancers are accessible localizations for the early diagnosis, once again underscoring the importance of epidemiological study that highlights the severity and features of the two cancers analyzed, also justifying the real need of the national and territorial cancer registry. CANCER REGISTRY. The cancer registries have emerged from the desire to know the real situation of morbidity and mortality from cancer, some operating obligatorily and others just optional. The registration of neoplastic disease can be defined as continuous and systematic collection of data on the occurrence and characteristics of the reported cancer cases with the scope to assess and control the impact of the cancer on the community. The cancer control programs require an epidemiological background provided by the cancer registries. Based on the epidemiological trends of the cancer can be underlain the primary and secondary prevention programs for cancer. The cancer registry is the service or institution that collects, stores, analyzes, interprets and reports the data on patients with cancer. Information is an important element in controlling the cancer, and only through a proper knowledge of the actual morbidity and mortality from cancer the fight against cancer can be supported and efficient. The population cancer registries, a proven method of epidemiological surveillance of neoplastic diseases, are considered by OMS as obligatory elements for the functioning of a National Cancer Control Plan. The institutional cancer registry or the registry based on hospitalized cases records all the cancer cases diagnosed and treated in a certain hospital, the information being used for administrative purposes and to assess the clinical performance. The data collected have a limited value to realize epidemiological studies, not possible to define precisely the population from which the cases raise. The main purpose of such registries is to improve the cancer (oncology) care by knowing detailed information about cancer patients in the hospital or clinic, received treatment and follow its evolution. The territorial cancer registry or the registry based on population seeks to collect data on all new cancer cases occurring in a defined population, usually the population resident in a given geographical area. Thus these registers collect and classify the information on all new cases cancer occurring in a geographically defined population, the main goal is to produce statistics about cancer in that population, providing a tool for evaluating and monitoring the impact of cancer in the community, which is important in epidemiological research and in the public health field. PURPOSE OF STUDY. Understanding and knowing of the real level of prevalence, incidence and mortality from cancer are important in the assessment of the impact on the public health and resource planning. The study on "Epidemiology of breast cancer and cervical cancer in the counties of Oltenia-epidemiological study 1984-2006" was conducted in five counties by collecting data and correcting, replenishment of the data from the registers of the county oncology departments. The main objective of the study was the increasing of the reporting quality of the incidence, prevalence and mortality cancer data.in order to achieve this goal in each of the five counties, there were recorded data over a period of 22 years, analyzing retrospectively the main aspects of morbidity by cervical cancer and breast cancer, two of the most common and responsible locations for most deaths from 3
cancer among the female population. The objectives proposed by this epidemiological study overlap on current trends in real-time computerization of the health system, to introduce the registers in as many affections which represent public health problems, namely the need to create real networks for data recording and analysis in health field. At present the epidemiology of cancer in many countries is already a field by itself, cancer is the second leading cause of death in the world, the measuring the phenomenon is a real need and a basis for establishing the health care programs. In this context, this study points precious data which have an impact on a period of 22 years in five counties, being representative of the pathology addressed. The study provides accurate scientific analysis useful for both policy makers and health professionals in many fields. The knowledge of the picture of the epidemiology of these diseases also allows for further detailed research and interventions on population groups targeted by preventive measures. MATERIAL AND METHODS. The study having the theme "Epidemiology of breast cancer and cervical cancer in the counties of Oltenia-Epidemiological study 1984-2006" was conducted in the counties: Dolj, Gorj, Olt, Valcea and Mehedinti, being a retrospective observational study over a period of 22 years.the analysis of morbidity and mortality of the two main female cancer sites, cancer of the cervix and breast cancer, was focused mainly on the classical indicators of incidence, prevalence and mortality. In this way, there were used all the cases which were diagnosed in women between 1 st January 1984 and 31 st December 2006. The data were obtained by introducing them in the database of the Regional Cancer Registry of Oltenia, namely by the onset of the cancer registry in Craiova and its developing the inclusion of the other counties of Oltenia. The data regarding the cases of cancer were obtained from the reporting type files. There were used also demographic data from the Yearbook of Health Statistics and population registry. The aim of this retrospective analysis was to provide a clear basis for the main epidemiometrical indicators, the data being analyzed for their impact on health policies, management of the control program and research priorities. RESULTS 1.BREASTCANCER: It was noticed the increase trend in the number of new cases in the period under review. Thus in 1984 there were 240 new cases in the whole region, but for the year 2006 to reach a total of 539 new cases of breast cancer, stating an increase of over 2.25 times the gross number of incident cases. The fluctuation in the number of cases ranged from 121 new cases in 1991 and 615 new cases in 2002. During the reported period the average number of cases was 383.13 ± 138.7 new cases / year with a median of 412, 11. In the annual frequency chart can be observed a particular aspect represented by a dramatic decrease in the 1990 (210 cases) and 1991 (135 cases). The characteristic of these years is given by the profound changes in the reporting system after1989. This gap is most probably the result of an underreporting of cases of cancer found in other official data provided by the various monitoring and reporting systems operating in that period. One third of the cases (36.02%) come from Dolj county through the 3199 new cases in the period under review. The average number of incident cases diagnosed with breast cancer was 139.09 ± 58.6 new cases per year. This first place in the top of breast cancer is explained largely due to the demographic 4
impact of the female population who are resident in the Dolj County and who represent 31.33% of the total female population of the region analyzed. The demographic decrease of the population is a reality of the period after 1989. The decrease in population at risk should correlate with the decreased of the incidence. The script is not validated, as it is seen from the steady increase in the number of new cases, the increasing of the number of new cases in the past 20 years is more than twice. Over the 22-years period the increasing of the incidence was stable in Oltenia, registering an increase of more than two times of the incidence during the interval. The incidence was expressed differently in the first period of the study, by a moderate increase compared with the average of the 1984-1989 period, in the next period (1990-1995) was recorded an incidence of 25.2 cases/100000, the increase being of 18.03 %. The dynamics of the growth doubles to 25.2 cases/100000 in the next period between 1984 and 1989 to 35.49 cases/10000 in the period between 1995 and 2001, the increase being of 40.33%. The last period of the study kept almost the same rate of growth, and in the period 2001-2006 the incidence was to peak of 47.12 cases /100000, the difference from the previous period being 32.71% higher. The average incidence of breast cancer in Dolj county was 36.48 cases/100000, ranging from a minimum of 9.37 cases/100000 to a maximum of 66.81cases/100000 recorded in 2003. Knowing the number of new cases and the number of the population at risk could been calculated the risk of breast cancer in women at different times. It was established so that compared with the period 1984-1989, the breast cancer risk was 1.24 times higher for the period 1990-1995 (RR = 1.24, 0.89 <RR <1.65, p = 0.12, NS ). The risk of breast cancer in female population of the county of Dolj increased 1.75 times in 1996-2000 (RR = 1.75, 1.35 <RR <2.26, p <0.005) compared with the reference period before 1990. The breast cancer risk for female population of Dolj county was the greatest in the last period of the study, between 2000 and 2007, for which the identified relative risk was almost 2.5 times higher (RR = 2.39; 1 87 <RR <3.06, p <0.005). For the Gorj County has been calculated an average incidence 23.93 cases/100000 (95% CI 19.31 to 28.55) for the entire period tracked. The average incidence of the Gorj County had the lowest value of the five counties. The incidence of breast cancer in female population in 1984 was 13.39 and that for 22 years later to record a value of 44.16 cases/100000 incidence. Comparing the two temporal extremes can be observed an increase in incidence over three times (3.31). in the minimum and maximum values were reached in 1987 (10.95 cases/100000) respectively in the year 2005 this indicator has expressed a value of 46.09 cases/100000. With a number of cases of 1214 and an average for female population at risk of 164624 women, the Mehedinti County had an incidence average of 32.4 cases /100000 (IC95% 26.31 to 38.70). Like for the rest of the counties it was noticed the increase trend of breast cancer incidence in female population of the Mehedinti county. The Olt County ranked second after Dolj County, as total (1925 cases) and average number of newly diagnosed cases of breast cancer of 84.83 cases per year. The reporting to the population at risk represented by the female population of the Olt County of 262142 women has provided a value of the average incidence of 32.64 new cases. The fluctuations in incidence occurred between a minimum value of 17.73 cases/100000 in 1990 and a maximum value of 72.27 cases/100000 in 2001. At the end of 22 years 5
examined in 2006 (44.96 cases/100000), the incidence was two times higher than that recorded at the beginning of the period (22.54 cases/100000). The average incidence of breast cancer in female population of Valcea county was 28.41 cases/100000 (IC95% 24.40 to 32.41) during the 1984-2006. The ratio between the recorded incidents in 2006 (33.07 cases/100000) and the incidence of the first analyzed year 1984 (17.95 cases/100000) showed an increase of 1.63 times. The evolution of the annual incidence of breast cancer in Valcea County was irregular being staggered by increases and decreases from one period to the other or from year to year. The period 1984-1989 showed an increase from 17.95 cases/100000 to 23.16 cases/100000, noticing a height of incidence in 1986 of 29.69 cases/100000. After falling to 10.43 cases/100000 in 1990, the incidence increases in "saw tooth" mode until 2003 when it reached the maximum of 22 years, of 48.56 cases/100000. Over the period 1990-2004 were recorded heights of the incidence in 1992 (30.47 cases/100000), 1994 (34.8 cases/100000), 1988 (38.14 cases/100000). After reaching the highest value in 2003, the incidence decreased to 26.26 cases /100000 in 2004, leveling off in the next years around 33 cases /100000. Regarding the analysis of prevalent cases of breast cancer, these increased steadily from 1461 in 1984 to 5211 in 2006, this increase being of 3.57 times compared with baseline from the beginning of the study. The increase of number was constant as is generally happening with the value of prevalent cases whose cumulative character ensures the increasing dynamics. The rhythm of the increase remarks a sudden increase in growth rate in 2004. This year the number of known was 5692 cases. The growth was almost five times higher than average annual growth rate recorded for the entire study (6.11%). The mechanism is the basis of the frequent differences in a higher prevalence of chronic diseases or those with long surveillance period compared with those with short duration, low survival and rapid healing. In this way, the growth of survival will influence positively by the increasing of prevalence. The Dolj County showed the largest prevalent cases at the end of 2006, the number of the known diagnosed cases of breast cancer was 2186. The annual average growth was 5.48%. The prevalence of breast cancer in Oltenia grew under the values of its frequency in Romania. For the five counties included in the analysis of this study the average prevalence was 233.25cases/1000. The value of the average prevalence of breast cancer recorded in the Oltenia region was 27.41% lower than the value of the average prevalence recorded in the whole country. Although the prevalence recorded in Oltenia had lower values than those reported in the country, not in all the counties the value of the prevalence was acting similarly. Being the county with the largest demographic representation of the female population, Dolj County recorded values higher than those observed for Romania on almost the entire period of the study. The limits expressed by the breast cancer prevalence ranged from a value of 178.92 cases/1000 in 1984 and a maximum value of 595.74 cases/1000 in 2006. The medium value of the prevalence of breast cancer in female population was 338.51 cases/1000, which was higher than the prevalence in the country (297.2 cases/1000) and higher than that recorded in the entire region analyzed (233.25 cases/1000). The increasing of prevalence in a period of 22 years between the values reached in1984 and the value reached in 2006 was 3.33 times. With an average prevalence of breast cancer of 189.97 cases /1000, the Gorj County is the county with the lowest prevalence among counties 6
Oltenia region. The prevalence recorded at beginning of the study, in 1984 was 70.87 cases/1000, being 1.51 times lower than the prevalence of breast cancer in Oltenia in 1984. At the end of the deployment period, in 2006 was recorded a prevalence of breast cancer 326.57 cases/1000, 4.58 times higher than the prevalence recorded at the beginning of the study. 2. Cervical cancer. In Romania the average number of new cases diagnosed with cervical cancer was 2543.78 new cases annually. The total number of new cases of cervical cancer diagnosed during the analyzed 22 years was 60653. The evolution of the number of cases had a clear upward trend. The number of new cases registered in 1984 was 2526 new cases, and at the end of 2006 the value of the number of new cases was 3053. The increase of the number of new cases observed compared to the reference value in 1984 was 21.1%. Oltenia region with its five counties in the period 1984-2006 contributed with 11.10% of new cases registered at national level, reported in the same period. The total number of new cases recorded in the whole region was 6730. The average annual number of new cases in Oltenia region was 291.74 new cases per year. As averages of the number of cases, Dolj County presented the highest value among the five counties of Oltenia region (94 new cases / year). A high value was noticed also for Olt County, where the average number of new cases annually was 64.78 cases per year. All the other counties in the region had similar values of the average number of new cases annually. So for Valcea and Gorj Counties the average number of new cases annually was 46.39 cases per year respectively 45.78 new cases per year. The county with the lowest representation on this indicator was Mehedinti County for which the value was 40.78 new cases per year. Among women in the county of Dolj, the total number of new cases diagnosed with cervical cancer reported in the analyzed period was of 2162 new cases. The largest share of the number of new cases of cervical cancer in Dolj County accounted for nearly one third of the number (32.22%) of cases registered at the regional level (6170 cases). For Dolj County the average annual value of the number of new cases was 94 cases per year, obviously being the highest value recorded in the counties of the region. For the whole Oltenia region was calculated an average incidence of 23.85 cases/100000. The values of the annual incidence ranged from a minimum value of the incidence of cervical cancer observed in 1991 by 9.94 cases/100000 and the maximum value observed in 2001 which expressed an incidence of 31.32 cases/100000. The average incidence of cancer in women from Oltenia region presented values similar to those registered at national level. All the five districts have expressed values close to what supports a uniform relative evolution of cervical cancer in the region. Mehedinti (24.92 cases/100000), Olt (24.81 cases/100000) and Dolj (24.54 cases/100000) expressed the highest values. At the opposite Valcea County showed the lowest value of the average incidence of cancer of the cervix (21.16 cases/100000), and along with the Gorj county with an average incidence of 23.28 cases/100000 emerges within counties with more than 24 cases/100000. The evaluation of annual incidence of cervical cancer in Dolj County at the beginning and end of the study showed synthetically the growth trend of 1.25 times, thus the risk of cervical cancer being1.27 times higher after 22 years corresponding to the period of the study (RR = 1.27 1.09 <RR <1.64, p = 0.017). The incidence of cervical cancer at the end of the study compared to that observed at the middle of the analyzed 7
period, year 1995 (19.17 cases/100000), revealed a risk of cervical cancer compared to that from the middle of the study of 1.4 times higher (RR = 1, 41, 1.11 <RR <1.98, p <0.005). The evolution of the prevalence of cervical cancer in women in Dolj County during the whole analyzed period was at higher levels than that recorded for the whole region. At beginning of the study (1984), the prevalence of cervical cancer has been identified twice (1.99) higher for women in Dolj county against women in the rest of the Oltenia region. The ratio falls below 1.5 at the end of the study, the prevalence in women in Dolj County being of 438.22 cases /100000 being compared with that in the rest of the region for which the value was 343.12 cases /100000. The number of prevalent cases known at the end of the study was of 1608 cases. The increase in number of cases registered at the end of the study (2006) was 2.02% compared to the number of cases related to in 1984 (796 cases), representing an additional volume of 812 cases prevalent cases. The average number of prevalent cases for the entire period under review was 1195.78 cases. The fluctuation of the yearly number of prevalent cases diagnosed with cervical cancer has evolved from variations of -18.09% in 1993 to 11.7% in 1987. The average value of the fluctuation of yearly number of prevalent cases of cervical cancer has recorded a yearly increase of 3.42%. As with the general developments in the region and country, Gorj County showed a substantial increase in the number of prevalent cases in the period 1984-1989, with 62.32% in the number of prevalent cases. Mehedinti County expressed the smallest difference (7.06%) in the average number of prevalent cases in 1990-1995 (318.5 cases per year) and that observed during 1984-1989 (297.5 cases per year). Olt County is the second county in the number of prevalent cases at the end of 2006. The difference between the number of cases recorded in 1984 (321 cases) and number of cases recorded in 2006 (797 cases) registered a volume growth of prevalent cases diagnosed with cervical cancer with 476 cases. The growth during the period was 2.48 times. The average annual number of prevalent cases was 545.13 cases per year, representing almost 20% (19.78) of the value of this indicator recorded in the entire region. The lowest number of prevalent cases of cancer of the cervix was observed in Valcea County (476 cases in the records registered at the end of 2006), over three times less than those reported in Dolj County. The share of prevalent cases among cases that are recorded at the end of the study was only 11.82% and 10.79% at the beginning. The difference between the number of prevalent cases recorded in 1984 and that reported in 2006 was 299 cases, the number of cases at the end of the study being 2.69 times higher than the year 1984.In Romania the average mortality of cervical cancer in the period examined by this study (1984-2006) was 14.66 deaths /100000. The fluctuation in mortality values ranged from a minimum value of 12.63 deaths/100000 registered in 1986 and the maximum of 16.93 deaths/100000 observed in 2003. For a period of 11 years mortality from cancer of the cervix should remain under 14 deaths/100000, this value being exceeded only in1988 (14.04 deaths/100000) and 1995 (14.09 deaths/100000). The mortality values exceed the critical threshold of 15 deaths /100000 in 1997 and remain above this threshold until 2002 that the jump occurs at values higher than 16 deaths 100000, maintaining themselves at high levels until the end of the analyzed period of 2006. For Oltenia region the average mortality during 1984-2006 was of 14.66 deaths /100000 being close to the average mortality observed in Romania for that period. There was noticed a difference between the maximum and 8
minimum value of mortality. The minimum value of cervical cancer mortality was observed in the study onset in 1985 (10.59 deaths 100000). The highest value of cervical cancer mortality was recorded 15 years later in 2000, when the value of mortality was 18.92 deaths /100000. The data were statistically processed in order to express risk of death from cervical cancer in Oltenia and in the five counties associated to Oltenia region. In order to show the risk of death was preferable the relative risk. It showed that the lowest risk of death in 2002-2006 compared with 1984-2989 period, was for women in Dolj county for which the value was 1.24 (RR = 1.24, IC95% 1.06 <RR <1.46, p = 0.008). At the opposite was Valcea County, where the death risk of cervical cancer was 1.64 (RR = 1.64, 1.29 <RR <2.09, p <0.005). For all the women of the whole Oltenia region, the risk of death for the period after 2002 (2002-2006) was 1.48 times higher than for women during the previous period of 1990 (RR = 1.48, IC95% 1 36 <RR <1.48, p <0.005). The mortality from cancer of the cervix in women in Dolj county had an average value for the 22 years of study of 15.05 deaths/100000 by the large share of deaths outlining the mortality in Oltenia (15.00 deaths / 100000). In retrospective study we have achieved, we had as objectives the highlighting the dynamics of the main indicators used to measure the burden of cervical cancer and breast cancer. As mentioned above the main purpose of the proposed study was the evaluation scale of the phenomenon through a detailed analysis by county, times and locations, providing a complete picture of morbidity and mortality most common locations cancer in women. Dolj County recorded the most cases for both diseases with the highest values of the indicators, sometimes even above the average per country In all the counties for both types of cancer has been seen a continuous significant increase, the same trend being reported at the country level, in contrast to the decreasing situation from the most Western European countries which already recorded a significant decrease in the incidence, prevalence and mortality, especially by cervical cancer. Given the striking results obtained in this study, we consider to be appropriate to introduce the policy priorities of health screening programs at the national population for these two sites, cancers proved to be real public health problems, programs that should exist in parallel with the programs for information and education for health. The organized screening programs at national and systematic level proven their efficiency in the world, leading to visible results. CONCLUSIONS. 1. Breast cancer incidence has increased during the period under review throughout the region and is growing across the country. Also, the disease prevalence and mortality of this disease follow the same growth. 2. Increasing incidence more than twice within 22 years n the whole Oltenia region and the demographic decline of the population at risk is not correlated with the decreased incidence of breast cancer, but on the contrary. 4. Dolj County presented the highest values of the incidence of breast cancer among all the counties in Oltenia, Dolj having an average incidence of 36.48 cases per 100,000, with the following limits: 9.37 cases per 100 000 in 1996 and 66.81 cases per 100,000 in 2003. 9
5. The female population risk of developing the disease increased steadily with each phase analyzed as follows: 1.18 times in 1990-1995 compared to the period before 1990, 1.41 times in 1996-2000 compared to 1990-1995. 6. The breast cancer risk for female population of Dolj County was the greatest in the last period of the study, that between 2000 and 2007, for which the identified relative risk was almost 2.5 times higher than the previous period of 2000. 7. Olt County ranked second after Dolj County, as the total number (1925 cases) and as average number of new diagnosed cases of breast cancer of 84.83 cases per year. 8. For Gorj County has been calculated an average incidence of breast cancer of 23.93 cases/100000 (95% CI 19.31 to 28.55) for the entire analyzed period, being the lowest value among the five counties, but with an increase of the incidence of over three times during the period studied. 9. The breast cancer marks by its frequency the most important public health problem among women affected by cancer, the average value of the prevalence for the period 1984-2006 was 297.2 cases/1000 women. 10. The number of prevalent cases of breast cancer in the Oltenia region also increased from 1461 cases in 1984 to 5221cases in 2006, this increase being of 3.57 times higher. 11. The average value of the prevalence of breast cancer in Oltenia was 233.25 cases per 1000 women which is below the country average of 297.2 cases per 1000, and the median value of the Dolj region is above the level of the region and country with an average of 338.51 cases per 1000, and the lowest average value was in Gorj county with 189.97 cases per 1000. 12. Dolj County showed the largest prevalent cases, at the end of 2006 the number of diagnosed cases of breast cancer was of 2186 cases, with an average annual growth of 5.48%. 13. With an average prevalence of breast cancer of 189.97cases/1000, the Gorj County is the county with the lowest prevalence among counties in the Oltenia region. 14. Oltenia region with its five counties in the period 1984-2006 contributed with 11.10% of new cases of cervical cancer registered at national level, respectively with 6730 cases. 15. As averages of the number of cases, Dolj County presented the highest value among the five counties associated to Oltenia region (94 new cases / year), representing almost one third (32.22%) of cases registered at the regional level. 16. With only 938 new cases registered with the diagnosis of cancer of the cervix, Mehedinti County presented the lowest volume of new cases of cervical cancer among all counties in Oltenia region. 17. In Dolj County the average incidence of cervical cancer among women in this county for the entire duration of the study was 24.54 cases /100000, being close to the recorded values and other counties, especially in the counties of Olt and Mehedinti. 18. For Oltenia the average mortality for cervical cancer during 1984-2006 was of 14.66 deaths /100000 being close to the average mortality observed in Romania for the same period. 19. For all the women within the whole Oltenia region, the risk of death by cervical cancer for the period after 2002 (2002-2006) was of 1.48 times higher than that of the women in the previous period of 1990. 10
20. The mortality from cancer of the cervix in women in Dolj county had an average value for the 22 years of the study of 15.05 deaths/100000 by the large share of deaths, drawing the mortality at the level of Oltenia region(15.00 deaths / 100000). SELECTIVE REFERENCES: 1. Adami H.O., Hunter D., Trichopoulos D., Textbook of Cancer Epidemiology, Oxford University Press, 2002. 2. Allen E. Bale, Suzanne J. Brown, Etiology of Cancer: Cancer Genetics, in De Vita Jr (ed): Cancer: Principles and Practice of Oncology, 6th Edition, Published by Lippincott Williams & Wilkins, Copyright 2001. 3. Allen T.F., Groningen B., Barksdale D.J., McCarty R., The breast self examination controversy: what providers and patients should know, The Journal for Nurse Practitioner, June 2010, vol. 6, issue 6, pg 444-451. 4. American Cancer Society. Cervical Cancer: Prevention & early detection, available at:http://www.cancer.org/docroot/cri/content/cri_2_6x_cervical_cancer_prevention_and_earl y_detection_8.asp. Accessed on August 2009. 5. Bădulescu F., Oncologie Generală, Craiova 1997. 6. Bădulescu F., Gorunescu F., Informatică oncologică, Metode statistico-informatice în oncologie, Editura Didactică şi Pedagogică, 2003. 7. Cancer Research UK. Cervical cancer - UK mortality statistics. Available at: http://info.cancerresearchuk.org/cancerstats/types/cervix/mortality/. Accessed on august 2010 8. Dragomir I.M., Bădulescu Fl., Ileana Prejbeanu, Michael Schenker, Registrul de cancer, Conferinta Nationala de sanatate publică, 16-18 noiembrie Timisoara 2007, publicat in extenso în monografia Oportunitati si provocari in sanatatea publica, in contextul integrarii Romaniei in Uniunea europeana Editura Brumar 2007, pg.225. 9. Dragomir I.M., Bădulescu Fl., Ileana Prejbeanu, Michael Schenker, Registrele de cancer actualitãti, Conferinta Nationala de sanatate publică, 16-18 noiembrie Timisoara 2007, Oportunitati si provocari in sanatatea publica, in contextul integrarii Romaniei in Uniunea europeana Editura Brumar 2007, volum de rezumate, pag. 43. 10. Dragomir I.M., Bădulescu Fl., Schenker M., Cancerul de col uterin in judetul Dolj European Journal of Public Health, vol. 17, S2, octombrie 2007, pg 154, a 15-a Conferinta Europeana de Sanatate Publica (EUPHA), 11-13 octombrie 2007 Helsinki, Finlanda. 11. Dragomir I.M., Badulescu F., Prejbeanu I., Dinescu S.N. Mihai M., Evoluţia incidenţei cancerului de col uterin în Oltenia Conferiţă regională Epidemiologia cancerului în judeţele olteniei.actualităţi în diagnosticul şi tratamentul cancerului glandei mamare şi cancerului renal, 4-5 iunie 2010 Dubova, volum de rezumate, pg 204. 12. Dragomir I.M., F. Badulescu, Prejbeanu I., Dinescu S.N., Mihai M., Cancerul de sân studiu retrospectiv-oltenia: 1984-2006 Conferiţă regională Epidemiologia cancerului în judeţele olteniei. Actualităţi în diagnosticul şi tratamentul cancerului glandei mamare şi cancerului renal,4-5 iunie 2010 Dubova, volum de rezumate, pg 197. 13. European Health for All databases (HFA-DB) [online database]. Copenhagen, WHO Regional Office for Europe, 2008 (http://www.euro.who.int/hfadb). 14. Engholm G., Ferlay J., Christensen N., Bray F., Gjerstorff ML, Åsa Klint, Jóanis E. Køtlum, Elínborg Ólafsdóttir, Eero Pukkala and Hans H. Storm (2009). NORDCAN: Cancer Incidence, Mortality, Prevalence and Prediction in the Nordic Countries, Version 3.5. Association of the Nordic Cancer Registries. Danish Cancer Society (http://www.ancr.nu). 15. Ferlay J, Parkin D.M., Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. European Journal of Cancer 2010;46:765-781. 16. Ferlay J., Shin H.R., Bray F., Forman D, C. Mathers and D.M. Parkin (2010). Estimates of Worldwide Burden of Cancer in 2008: GLOBOCAN 2008. Int J. Cancer 17. Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: Cancer Incidence. Mortality and Prevalence Worldwide. IARC CancerBase No. 5, version 2.0., Lyon: I.A.R.C. Press 2004. 18. Ferlay J., Bray F., Piscini P. et al. GLOBOCON 2000. Cancer incidence, mortality and prevalence worldwide 2001. 11
19. Garcia-Closas, M., Brinton, L.A., Lissowska, J., et al Established breast cancer risk factors by clinically important tumour characteristics Br J Cancer 2006; 360:187-95. 20. I.A.R.C.: Section of Cancer Information (CANCERMondial) http://www-dep.iarc.fr. 21. I.A. R. C. Cancer Epidemiology, priciples and methods, Lyon, France, 1999. 22. World Health Organisation, National cancer control programmes, Policies and managerial guidelines 2 nd edition, Geneva. 23. World Health Organisation (WHO) Databank, Geneva, Switzerland. WHO Statistical Information System http://www.who.int/whosis. 24. WHO (mortality data): http://www.who.int/whosis/mort/download/en/index.html. 25. WHOSIS (WHO Statistical Information System) [web site]. Geneva, World Health Organization, 2008 (http://www.who.int/whosis/ en/). Name: Dragomir Iuliana Manuela Date of birth: 7.05.1974 Marital status: Married, one child. Phone: 0740 32 87 89 E-Mail: manueladragomir@yahoo.com CURRICULUM VITAE 1998 : Gratuated Faculty of Medicine, University of Medicine and Pharmacy Craiova. 2002: Teaching assistant in Public health and management, Faculty of Medicine Craiova. 2003 Specialist in Public health and management. 2009 Lecturer in Public health and management, Faculty of Medicine Craiova. Author of 2 books in Public health and management. Number of summarized scientific studies published national and international: 62 Number of extenso paper: 12 Research activity: member of 2 Grants of UMF: (CANREGOLT: Oltenia Cancer Registry), 41016/2007, Project director Prof. Univ. Dr. Florinel Bădulescu, and a PNCD II Grant with contract number CNCSIS 927/2009 named Anthropological and psychomedical links of sexual reproductive health on rural and urban population, Project director Prof. Univ. Dr. Ileana Prejbeanu. Actual employee: University of Medicine and Pharmacy Craiova, Lecturer in Public health and management, Faculty of Medicine. 12