2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Some unsolved problems and disparities still persist in the
management of patients with lung cancer because of a
generally underfinanced health care system. Although a highquality
disease management program can be offered in many
of the Romanian specialized cancer units, problems persist
related to the access to a complete diagnostic work-up and an
immediate multidisciplinary treatment. Each of the 40 counties
in Romania have at least one oncology department
(medical oncology with or without radiation oncology). The
largest are the Cancer Institutes “Alexandru Trestioreanu”
in Bucharest and “Ion Chiricuta” in Cluj-Napoca, with a
third one recently inaugurated in Iasi.
Fiberoptic diagnosis is performed by 150 pneumologists,
but bronchoscopy departments are lacking in nine counties.
The number of bronchoscopies per year raised continuously
between 1990 and 2010 (2,100 vs. 10,000 procedures). This
represent an overload of the main four centers (Bucuresti,
Cluj, Timisoara, and Iasi), which together perform 75% of all
the examinations. Lack of sufficient modern bronchoscopes
or biopsy devices, lack of specialized pathology and cytology
departments (decreased diagnostic accuracy), and lack of
sufficient intensive care and thoracic surgery departments
(avoidance of the procedures with a higher risk of complications)
have a negative effect on the quality of diagnosis. 3
Thoracic surgery has evolved, but radical surgical treatment
is confined to few specialized university centers.
Twenty nine centers have radiotherapy facilities throughout
the country, served by 110 radiation oncology specialists.
However, a recent analysis revealed that overall, the equipment
is outdated and insufficient—only 16 centers have
high-energy radiotherapy machines (11 linear accelerators
and 15 telecobalt machines, 6 of them outdated). It is
estimated that only 27% of the patients that require radiotherapy
have access to treatment, mostly because of a lack of
facilities. There is one megavoltage machine per 1 million
inhabitants, even though the European Union standard
recommends one machine per every 300,000 inhabitants. 7
Therefore, concomitant chemoradiotherapy is rarely used,
KEY POINTS
● The officially recommended standard of care in Romania
is in agreement with the 2009 European Society
for Medical Oncology guidelines.
● Antitobacco policies are in place, following the
MPOWER strategies recommended by the WHO.
● Lung cancer treatment in Romania is free and funded
by a National Program of Oncology, with the exception
of pemetrexed and targeted treatments, which
are individually reimbursed following the decision of
a centralized National Commission.
● Although new treatments are promptly registered in
Romania through a common European procedure, the
decision for reimbursement is a multistep bureaucratic
process that may take several years.
● Romanian centers consistently contributed to recent
research in lung cancer, and clinical research is
rapidly growing, despite delays related to the initial
approval by authorities.
438
Table 1. Smoking Prevalence during the Lifetime, Romania, 2004*
Gender %
Male 75.4
Female
Age Group (years)
48.7
15–24 61.8
25–34 70.5
35–44 65.0
45–54 62.7
55–64
Education
44.2
Primary school (8 yr) 33.3
Secondary school (12 yr) 65.8
High school, university
Income
76.0
Low 58.5
Medium 67.6
High
Place of residence
82.0
Rural 53.9
Small town 67.5
Big city
Geographical region
68.5
Moldova 62.9
Muntenia 54.6
Transilvania 68.2
Bucharest 73.0
Total 62.1
* Source: Center for Health Policies and Services.
with the sequential approach permitting the scheduling of
radiotherapy.
Chemotherapy and targeted therapy are delivered by the
270 specialists in medical oncology. Optimal chemotherapy
can be offered by medical oncology departments throughout
the country in a timely manner. The registration of new
drugs is simultaneous with the European Medicines Agency
registration. The access to some expensive new molecules is,
however, limited because of the reimbursement policies.
Strategies for Tobacco Control
TUDOR E. CIULEANU
A study carried out in Bucharest, between 1999 and 2001,
found 84% of 8,856 patients with lung cancer were smokers. 3
Data from the Center for Health Policies and Services show
a prevalence of smoking in the general population of 62.1%
during the entire life. 8 The prevalence was higher in men
age 25 to 34 years, with a high education level, high income,
and from urban areas (Table 1). A study published in 2006
ranked Romania 29 of 30 European countries in respect to
the total measures taken to control tobacco smoking. The
score was based on price, public place bans, public information
campaign spending, advertising bans, health warnings,
and treatment. 9
The WHO Framework Convention on Tobacco Control
(WHO FCTC) and its guidelines provide the foundation for
countries to implement and manage tobacco control. The
WHO introduced the MPOWER measures, intended to assist
in the country-level implementation of effective interventions
to reduce the demand for tobacco. Romanian
tobacco control strategy follows the MPOWER measures
recommended by the WHO:
● Monitoring of tobacco use and prevention policies. A
periodical monitoring of smoking is done every 2 years.