Cancer Deaths in Russia Greatly Exceed Those in US and Europe

Roxanne Nelson

April 25, 2014

Cancer mortality rates in Russia greatly exceed those in Europe and the United States, according to a report on the challenges to effective cancer control in China, India, and Russia, which was published in the April issue of the Lancet Oncology. About a quarter (26%) of all cancer patients will die within a year of their diagnosis, although this rate varies considerably by geographic region.

Russia is both a high-income country and an emerging economy, as defined by the World Bank. But despite this distinction, life expectancies have not risen in line with the increasing wealth of the country and, notably, cancer accounts for 15% of all deaths.

In Russia, the overall risk of dying from cancer is about 60%, which is higher than the 40% in the United Kingdom and the 33% in the United States.

The mortality-to-incidence ratio, an indirect measure of cancer survival, is higher for Russian men than Russian women (0.72 vs 0.49). It is also higher than for American men (0.36) and European men (0.44).

There are a number of reasons Russia faces such a daunting cancer burden, according to the report. For one, economic disparities are extreme and people living outside of major cities have inadequate access to cancer care facilities. The distribution of facilities throughout the country is uneven, and the disparity is most pronounced when comparing urban and rural areas.

Historically, the majority of specialty centers were located in Moscow and St. Petersburg, where only 12% of the population resides. There have been recent efforts to improve this, according to the report, but rural and remote populations remain largely underserved, with no access to basic facilities or qualified healthcare providers.

Only 30% of Cancer Patients Receive Radiation

Since the dissolution of the USSR in 1991, the availability of radiation therapy has declined, note the authors of the report, led by Paul E. Goss, MB BCh, PhD, professor of medicine at Harvard Medical School and director of breast cancer research at the Massachusetts General Cancer Center in Boston.

In Russia, only 30% of cancer patients receive radiation therapy, primarily because of a lack of financial resources, equipment, training, and personnel. In other developed countries, about 70% of patients receive radiation therapy.

Healthcare spending for the poor is also very low, compared with countries with a similar income level. These inequities in funding and access to treatment make optimum cancer care unavailable to many patients.

Another pressing issue is the prevalence of tobacco and alcohol use, which has an enormous economic and human toll. Russia has been classified as "most risky" by the World Health Organization because of the high consumption of alcohol and the pattern of binge drinking. However, there is insufficient commitment to reduce smoking and alcohol use.

"New public health initiatives to tackle smoking and harmful alcohol use are a welcome first step in tackling the preventable burden of cancer in Russia, but these campaigns now need to be adequately enforced and monitored, which will require substantially more political commitment and resistance to influences from industry than we are currently seeing," Dr. Goss said in a statement.

Tumultuous Changes

Although healthcare spending has risen from $113 per person in 1995 to $807 per person by 2011, the report authors point out that the proportion of public funding for healthcare decreased from 73.9% in 1995 to 59.7% in 2011. Thus, out-of-pocket expenses increased for patients.

The Russian healthcare system continues to be challenged by the tumultuous economic and political environment and the growing burden of noncommunicable diseases, which are now the most common causes of death, illness, and disability in the country.

In 2012, there were 525,931 new cases of cancer registered in Russia (240,938 in men and 284,993 in women). The most common malignancy in Russian men was lung cancer (51.4 per 100,000), followed by prostate cancer (30.1 per 100,000) and colorectal cancer (30.0 per 100,000).

Breast cancer is the most common cancer in Russian women. The annual incidence is substantially lower than in the United States (45.6 vs 92.9 per 100,000), but mortality is higher (17.2 vs 14.9 per 100,000). The second most frequent cancer in women is colorectal, followed by endometrial and cervical cancer.

Improvements to the system and increased funding could enhance cancer control in Russia. These strategic initiatives include "increasing healthcare expenditure to about 10% of GDP, and increasing of the percentage of resources allocated to cancer control," the authors note. Also needed are more investment in healthcare infrastructure and the delivery of prevention and treatment services for cancer, and "ensuring of equitable distribution of funding, specifically to indigenous populations and populations that are socioeconomically and geographically disenfranchised."

Enormous Use of Tobacco and Alcohol

Although increased investment in healthcare would address many of the issues impeding cancer care, efforts to prevent cancer also need to be addressed, say the authors. The impact of cancer and other diseases related to modifiable lifestyle choices, such as smoking and alcohol misuse, is enormous.

There are an estimated 44 million smokers in Russia (60.2% of men and 21.7% of women). It is not surprising that lung cancer is the number 1 cancer and the number 1 cause of cancer-related death in men. In addition, overall mortality for all tobacco-related cancers (e.g., bladder, head and neck, kidney, gastric, and pancreatic cancer) is higher in Russia than in either the European Union or the United States.

The authors note that tobacco companies are increasingly targeting women. In addition, smoking rates are high in teens and young adults, passive smoke exposure is common, and an estimated 330,000 to 400,000 people die each year from tobacco-related causes. Attempts have been made to restrict smoking, but these are widely ignored, primarily because they are poorly enforced, fines are low, and there have been "challenges" from the tobacco industry, the authors report.

Alcohol misuse takes a significant toll, with an estimated 500,000 deaths annually from alcohol-related disorders. Alcohol-related cancers — such as those of the head and neck, esophagus, liver, and colon — are common in Russia, and the death rate is high. The mortality-to-incidence ratio for head and neck cancer, for example, is nearly 3 times higher in Russia than in the United States.

Uneven Cancer Screening

Cancer screening is uneven in Russia. Currently, screening is only recommended for breast and prostate cancer; there are no national public health initiatives that support screening for cervical or colorectal cancer. The incidence of cervical cancer is higher in Russia (15.9 per 100,000) than in the European Union (9.6) or the United States (6.6), and it is a common cause of cancer death.

Breast cancer screening is available in Russia, but there are few data on the extent of this screening, and access varies by region, according to the authors. In addition, the scientific literature in Russia shows that there is a lack of data on the socioeconomic and cultural barriers to breast screening and breast healthcare. The incidence of metastatic breast cancer at diagnosis is much higher than in the United States, which has widespread screening programs and community awareness.

Even though colorectal cancer is the second most common cause of cancer death in women and the third most common cause in men, screening for this disease is not part of the National Priority Project Health, which provides guidelines for cancer prevention efforts in Russia, the authors point out. A quarter of all cases are diagnosed at stage IV, compared with 19% in the United States. One-year survival for colorectal cancer is lower in Russia than in Australia or the United States (72.1% vs 82.2% vs 82.3%). These numbers suggest that the cancer is diagnosed at a more advanced stage and/or that patients receive suboptimum treatment, the authors explain.

Increase Efforts for Primary Prevention

Primary prevention efforts need to be increased. "From an economic standpoint, effective prevention and early detection yield benefits that far exceed costs," write Dr. Goss and colleagues.

A comprehensive national prevention plan for cancer that includes efforts to reduce the use of tobacco and alcohol needs to be established. Regulations need to be enforced and strengthened, and strict antitobacco and antialcohol policies are needed.

In addition, cancer screening programs need to be organized at a national level, taking local needs and available resources into account. For example, in areas with a high incidence of cervical cancer, screening programs should be considered, along with human papillomavirus (HPV) vaccination.

Another part of the prevention program should focus on the decontamination and remediation of polluted lands, the authors suggest. There are a number of areas in Russia that have alarming rates of cancers directly related to environmental contamination, they point out. Russia has suffered from severe environmental degradation; in the 1990s, 40% of the land was considered to be "environmentally stressed" because of deforestation, irresponsible energy production, pollution, and nuclear waste.

Diagnosis and Epidemiology

Other priorities for cancer control are improvements in diagnosis and better documentation of cancer demographics and outcomes.

High-quality radiology and pathology services are needed for an accurate cancer diagnosis, but information about the availability of diagnostic radiology in cancer care is scant, says the report. Although there are no data on the number of MRI, CT, or PET scanners, or the availability of mammography equipment, anecdotal evidence suggests that some regions are well supplied. However, media reports from Russia suggest that that the demand is not being met, and that there are shortages of both equipment and personnel.

Pathology services are also problematic. Currently, high-quality pathologic diagnoses can only be guaranteed in a few specialized medical centers in Moscow and St. Petersburg. In addition, only a small number of laboratories have extensive experience with immunohistochemistry. Pathologists in Russia have been traditionally trained for postmortem analysis, so funding and health regulatory standards for premortem diagnostic pathology have been lacking, according to the authors.

Therefore, along with providing increased patient access to surgical treatment, radiation therapy, and therapeutic agents, diagnostic services for radiology and pathology need to be improved and standardized, the authors recommend.

Finally, accurate documentation of cancer demographics and outcomes must "be a priority for policy makers," they note.

Russia needs to establish a comprehensive national cancer plan that takes into account the distribution and burden of cancer in the country. Although the National Cancer Registry collects annual data on cancer incidence and mortality, along with other data, it remains unclear how representative it is of the nation as a whole, and a lack of transparency could be affecting efforts to fully comprehend the scope of the problem.

"Lack of access to information, poor prevention and early detection, and suboptimum treatment result in diagnosis of cancer at a late stage, and therefore reduced survival," the authors write. "Interventions for prevention and early detection need a series of legislative actions, public awareness campaigns, and public health interventions."

Coauthor Pedro E.R. Liedke, MD, from Clínicas de Porto Alegre, Instituto do Câncer Hospital Mãe de Deus, in Brazil, reports receiving travel grants from Roche, sanofi-aventis, and Novartis, and consulting for Novartis.

Lancet Oncol. 2014;15:489-538. Abstract

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