TABLE OF CONTENTS

BACK COVER

Colombia Médica v49n1 -Back cover PDF

Colombia Médica Colombia Médica 1-8

EDITORIAL
Epidemiology of cancer in Colombia Luis
Eduardo Bravo, Nubia Muñoz 9-12

Public health and epidemiology of cancer in Colombia

Carolina Wiesner 13-15

ORIGINAL ARTICLES
Cancer incidence estimates and mortality for the top five cancer in
Colombia, 2007-2011
Constanza Pardo, Ricardo Cendales 16-22

Reliable information for cancer control in Cali, Colombia

Luis Eduardo Bravo, Luz Stella García, Paola Collazos, Edwin 23-34
Carrascal, Oscar Ramírez, Armando Cortés, Marcela Nuñez,
Erquinovaldo Millán

Trends in cancer incidence and mortality over three decades in Quito -

Ecuador
Fabian Corral Cordero, Patricia Cueva Ayala, José Yépez Maldonado, 35-41
Wilmer Tarupi Montenegro

Trends in cancer incidence, and mortality in Pasto, Colombia. 15 years

experience
María Clara Yepez Chamorro, Daniel Marcelo Jurado Fajardo, Luisa 42-54
Mercedes Bravo Goyes, Luis Eduardo Bravo

Cancer incidence and mortality in Barranquilla, Colombia. 2008-2012

Rusvelt Vargas Moranth, Edgar Navarro-Lechuga 55-62

Health inequities and cancer survival in Manizales, Colombia: a

population-based study

Nelson Enrique Arias-Ortiz, Esther De Vries 63-72

Cancer incidence and mortality in Bucaramanga, Colombia. 2008-2012

Claudia Janeth Uribe Pérez, Sergio Serrano-Gómez, Claudia Milena 73-80
Hormiga Sánchez

Cancer incidence and mortality in Medellin-Colombia, 2010-2014

Mary Ruth Brome Bohórquez, Diego Montoya Restrepo, Liseth Amell 81-88

Oncology services supply in Colombia

Eliana Marcela Murcia Monroy, Jairo Aguilera, Carolina Wiesner, 89-96
Constanza Pardo

Pediatric oncology services in Colombia

Amaranto Suarez Mattos, Jairo Aguilera, Edgar Augusto Salguero, 97-101
Carolina Wiesner

Breast and cervical cancer survival at Instituto Nacional de

Cancerología, Colombia
Constanza Pardo, Esther de Vries 102-108

TECHNICAL REPORT
Cali Cancer Registry Methods

Luz Stella Garcia, Luis Eduardo Bravo, Paola Collazos, Oscar 109-120
Ramirez, Edwin Carrascal, Marcela Nuñez, Nelson Portilla,
Erquinovaldo Millan

Quality of death certification in Colombia

Ricardo Cendales, Constanza Pardo 121-127

Cancer risk management in Colombia, 2016

Paula Ramírez-Barbosa, Lizbeth Acuña Merchan 128-136
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Editorial

Epidemiology of cancer in Colombia

Epidemiología del cáncer en Colombia

Luis Eduardo Bravo1, Nubia Muñoz2

1
Editor asociado, Revista Colombia Médica, Universidad del Valle, Cali, Colombia.
2
Professor Emérita del Instituto de Cancerología de Colombia

Bravo LE, Muñoz N . Epidemiology of cancer in Colombia. Colomb Med (Cali). 2018; 49(1): 09-12. doi:10.25100/cm.v49i1.3877.

© 2018. Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

In this special issue dedicated to cancer, Colombia Medica discloses
an analysis of the cancer situation in Colombia and Ecuador. The
analysis is based on the data collected and analyzed by several
Population-based Cancer Registries (PBCR), carried out with
an inter-institutional collaborative effort of public and private
Colombian universities, Municipal and Provincial Secretaries of
Health, and the Ministry of Health and Social Protection through
the National Institute of Cancer of Colombia; and of the Fight
Cancer Foundation of Ecuador, SOLCA-Core of Quito. This
valuable contribution of the academic sector to the control and
surveillance of cancer in Colombia needs reciprocity from the
Ministry of Health. It is necessary to regulate the participation of
RPC in the cancer information system; and to assign permanent
resources to guarantee their sustainability.
For forty years the Population-based Cancer Registry of Cali (RPC-
Cali) was the only source of valid information on the incidence
of cancer in Colombia1. To increase coverage, the National
Cancer Institute of Colombia (NCI-Col), with the advisory of
the Universidad del Valle, promoted during the first decade of
the XXI century the creation of PBCR in strategic regions of the
country. Thanks to this effort, the incidence information of the
Colombian cities of Pasto, Manizales and Bucaramanga was added
to that of Cali and published since 2012 in Cancer Incidence in
Five Continents2, and the four Colombian RPC participated
in the CONCORD3  study, the global monitoring program for
cancer survival. Due to advances in cancer control and the great
strength of its RPC, Cali is the first city in the world to implement
the initiative “C/Can 2025: Challenge of Cities Against Cancer;”
a project of the Union for International Cancer Control (UICC)
that seeks to increase the coverage and quality of oncological care
in cities with more than one million inhabitants in low and middle
income countries4.
In this issue of Colombia Medica, the PBCR-Cali describes the
principles and methods used to analyze 50 years of incidence
(1962-2012), 30 years of mortality (1984-2014) and 15 years of
survival data (1995-2009)5. Six Colombian PBC-Registries and one
Ecuadorian PBC-Registry show the collection, classification and
analysis of all new cancer cases and cancer deaths that occurred
in Quito, Cali, Pasto, Bucaramanga, Manizales, Barranquilla and
Medellín during the period 2008-20126-12.
The Population-based Cancer Registries of Cali, Quito and Pasto
have at least 15 years of good quality information and present
valid results of cancer incidence and mortality trends in their
respective populations6-8.
The PBCR-Cali 7, PBC-Manizales10 and the hospital-based cancer
registry (HBC-Registry) of the NCI-Colombia13, the only HBC-
Registry in the country, present survival data for the types of
cancer with the highest morbidity in Colombia: prostate, breast,
cervix, colon and stomach.
Data analysis shows that there is a significant decrease in the
incidence and mortality rates of the infectious-related cancers and
tobacco-related cancers; and an increase in the incidence rates
of cancers related to early detection activities (breast, prostate,
colon) and new diagnostic techniques (thyroid cancer)6-8.
Barranquilla and Medellín report for the first-time data on the
incidence of cancer11,12. Barranquilla, a coastal city and the main
economic center of the Colombian Caribbean region, shows the
highest incidence rates of breast and cervix uteri cancer, while
its rates for gastric cancer and all cancer sites are the lowest in
Colombia. It is important to conduct specific investigations to
determine if these differences are the result of including non-
resident cases, duplication and/or information under reporting.

Corresponding author:
Luis Eduardo Bravo: Director Registro Poblacional de Cáncer de Cali, Escuela de Medicina,
Universidad del Valle, Cali, Colombia. e-mail: luis.bravo@correounivalle.edu.co
9
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Medellín, located in the Andean mountains of northwestern
Colombia, is the second most populated city in the country, with
particular demographic characteristics; it presents the incidence
for cancers prioritized by the Ten-Year Plan for Cancer Control
in Colombia. It should be noted that nearly 100% of new cases
of cancer registered have morphological verification12, so that the
results correspond more to a Population Registry of Pathology.
In this sense, the information on the risk of cancer in Medellín is
most probably underestimated since it does not include cases with
a clinical or imaging diagnosis and those whose only evidence of
cancer is the death certificate. Therefore, the rates for Medellín are
not comparable with those of other Colombian PBC-Registries.
The NCI-Colombia characterizes the current situation of the
supply of oncological services in Colombia14, and it demonstrates
that the certification of cancer deaths in Colombia is of good
quality15. The NCI-Colombia uses the information from four
cancer registers7-10and the official mortality figures, to make valid
estimates of cancer incidence for the entire country and for each
one of the provinces in Colombia15. The cancer risk estimates
for Colombia will be more precise when the information from
Barranquilla11 and Medellín12 can be included in the future.
Figure 1 shows the location of the RPC-Colombians, and Table
1 the incidence rates for the five leading causes of cancer morbidity
in Colombia, prioritized by the Ten-Year Plan for Cancer Control,
2012-2025.
To estimate risk measures, PBC-Registries must have a delimited
registry area and a clear definition of “case”. In this definition, it
is critical to include only the new cancer cases diagnosed in the
permanent residents of the city and to exclude the cancer cases
of patients referred to the city for diagnostic and/or treatment
procedures. The data collection must be both passive and active in
the different sources of information.
PBC-Registries require adequate and sustained resources to be
successful. In Colombia, the per capita registration cost varies
between US $0.05 to US $0.22. Between 20% and 45% of the total
cost is due to activities with a fixed cost. Universities have been
the main source of financial resources and of both scientific and
technical personnel, which has allowed them to be successful.
Another success factor of the PBC-Registries is the social
recognition in the city, facilitating the process of data collection.
The report of NCI-Colombia14 shows this reality concerning
oncological services in the country, the system serves 63,000 new
cases of cancer annually 16. Colombia has 1,780 habilitated services,
but only 25 providers offer joint chemotherapy, radiotherapy and
surgery services. Nearly 50% of the offer is concentrated in Bogotá,
and the provinces of Antioquia and Valle del Cauca; 87.8% is
offered by Institutions, and 12.2% by independent (health)
professionals. 66.7% of the oncology services are outpatient,
17.4% of diagnostic support and therapeutic complementation
services, and 15.9% of surgical services; 87.9% of the offer of

Barranquilla
1,224,000 h

Venezuela
Bucaramanga
1,100,000 h

Medellín
2,400,000 h

Manizales
400,000 h

Cali
2,300,000 h

Pasto
350,000 h

Quito

Brasil
Ecuador

Perú

Figure 1. Location of the Population-based Cancer Registries in Colombia. The physical location of the RPC-Colombians
is linked to their administrative dependency; all are in universities, except for the PBC-Antioquia, which is located in
the Provincial Health Secretariat. The universities have been the main source of financial resources and of scientific and
technical personnel for the PBC-Colombians; its directors have academic and research experience Data are inhabitant.

10
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Table 1. Rates of cancer incidence (100,000 persons-year) for the most frequent cancers, prioritized in the Ten-Year Plan for Cancer
Control in Colombia.
Colon C18-C21 Stomach C16
Region Breast C50 Prostate C61 Cervix C53
♂ ♀ ♂ ♀
1. Cali 44.3 59.7 15.3 16.2 14.0 20.2 10.7
2. Pasto 27.7 27.3 18.0 8.4 9.0 26.7 11.8
3. Bucaramanga 41.2 40.9 13.0 14.3 13.7 17.1 10.2
4. Manizales 37.2 44.1 17.5 14.7 14.7 20.3 9.7
5. Barranquilla 65.7 43.0 26.6 9.6 9.8 4.4 2.2
6. Medellín 36.5 38.6 8.5 7.5 6.9 12.4 8.1
7. Colombia-INC 33.8 46.5 19.3 12.2 12.3 18.5 10.3
8. Quito-Ecuador 38.8 62.9 18.6 13.2 11.9 20.3 14.5

oncological services in Colombia is in the private sector. There is Conflict of interest: 

clear evidence of fragmentation in the provision, so it is necessary
to redefine the services and to make a comprehensive oncological
care approach for the diagnosis and treatment of patients with
cancer, in order to improve clinical outcomes.
Despite this wide range of services, the 5-year global survival of
childhood cancer in Cali (51%) is between 26% and 32% below
the reported results for affluent countries (77% to 83%). This
means that, if around 1,500 to 1,600 children with cancer are
treated in Colombia each year, 765 to 816 die within 5 years after
diagnosis. Of these, 390 to 512 deaths per year would be avoidable.
This survival gap is maintained in all groups of neoplasms, except
for Hodgkin’s lymphoma (88% vs 95%). In adults, the situation
is similar; the 5-year net survival to prostate, cervix and breast
cancer is between 20 and 30 points below that observed in North
America and Europe. During the period 2000-2004, the 5-year
net survival improved for cancers of the breast, cervix, prostate,
melanoma and thyroid, although in the period 2005-2009, it was
observed a stagnation. In stomach, liver and lung cancer, the
5-year net survival was less than 15%7.
The PBC-Manizales  analyzed the differences in the survival for
10
breast, cervix, lung, prostate and stomach cancers; it highlights
the existence of important inequities in cancer survival related
to health insurance and socioeconomic status, attributable to the
barriers and delays in obtaining diagnostic care that are associated
with more advanced stages at the time of diagnosis.
None to declare
Referencias
1. Bravo LE, Collazos T, Collazos P, García LS, Correa P. Trends
of cancer incidence and mortality in Cali, Colombia. 50 years
experience. Colomb Med (Cali). 2012; 43(4): 246-55.
2. Forman D, Bray F, Brewster DH, Gombe MC, Kohler B, Piñeros
M, et al (eds). Cancer Incidence in Five Continents, Vol. X. Lyon:
International Agency for Research on Cancer; 2013. Available
from: http://ci5.iarc.fr. 
3. Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M,
Nikšić M, et al. Global surveillance of trends in cancer survival
2000-14 (CONCORD-3): analysis of individual records for
37 513 025 patients diagnosed with one of 18 cancers from 322
population-based registries in 71 countries. Lancet. 2018 Mar
17;391(10125):1023-1075. doi: 10.1016/S0140-6736(17)33326-3.
4. Bravo LE, Arboleda OI, Ramirez O, Durán A, Lesmes MC, Rendler-
García M, et al Cali, Colombia, Key learning City C/Can 2025: City
Cancer Challenge. Colomb Med (Cali). 2017;48(2):39-40
5. García LS, Bravo LE, Collazos P, Ramírez O, Carrascal E, Nuñez
M, Portilla N, Millán E. Cali Cancer Registry Methods. Colomb
Med (Cali). 2018; 49(1): 109-20.

The HBC-Registry of NCI-Colombia13, Colombia’s only hospital-
based cancer registry, analyzed survival in 1,928 cases of breast
cancer and 1,189 cases of cervix uteri cancer. The estimated overall
survival probability was 79.6% for breast cancer and 63.3% for cervix
uteri cancer. Overall survival was 32.2% for stage IV breast cancer
and 22.6% for stage IV cervical cancer. These survival estimates are
like those reported by the cancer-registries4,7,10; It would be expected
that the survival estimates in a cancer center would be higher than
the estimates observed by the cancer registries. It is necessary to
review the guidelines for clinical management in cancer patients
treated at the NCI-Colombia.
In Conclusion, the pioneer effort of the population-based Cancer
registry of Cali and of the Universidad del Valle and their
collaboration with other academic and public institutions has
made possible a precise estimation of the cancer burden in various
regions of Colombia and in Quito, Ecuador; this information is
basic and essential in the planning of strategies for cancer control.
11
6. Cueva AP, Yepes MJ, Turupi MW. Trends in cancer incidence
and mortality over three decades in Quito - Ecuador. Colomb
Med (Cali). 2018; 49(1): 35-41
7. Bravo LE, García LS, Collazos P, Carrascal E, Ramírez O, Cortés
A, Nuñez M, Millán E . Reliable information for cancer control in
Cali, Colombia. Colomb Med (Cali). 2018; 49(1): 23-34.
8. Yepez MC, Jurado DM, Bravo LM, Bravo LE. Trends in cancer
incidence, and mortality in Pasto, Colombia. 15 years experience.
Colomb Med (Cali). 2018; 49(1): 42-54.
9. Uribe PCJ, Serrano GSE, Hormiga SCM. Cancer incidence and
mortality in Bucaramanga, Colombia. 2008-2012. Colomb Med
(Cali). 2018; 49(1): 73-80.
10. Arias-Ortiz NE, de Vries E. Health inequities and cancer
survival in Manizales, Colombia: a population-based study.
Colomb Med (Cali). 2018; 49(1): 63-72.
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
11. Vargas Moranth R, Navarro Lechuga E. Cancer incidence and
mortality in Barranquilla, Colombia. 2008-2012. Colomb Med
(Cali). 2018; 49(1): 55-62.
12. Brome Bohórquez MR, Montoya Restrepo DM, Salcedo LA.
Cancer incidence and mortality in Medellin-Colombia, 2010-
2014. Colomb Med (Cali). 2018; 49(1): 81-88.
13. Suarez MA, Aguilera J, Salguero EA, Wiesner C. Pediatric
oncology services in Colombia. Colomb Med (Cali). 2018; 49(1):
97-101.
12
14. Cendales R, Pardo C. Quality of death certification in
Colombia. Colomb Med (Cali). 2018; 49(1):121-127
15. Pardo C, Cendales R. Cancer incidence estimates and mortality
for the top five cancer in Colombia, 2007-2011. Colomb Med
(Cali). 2018; 49(1): 16-22.
16. Pardo C, de Vries E. Breast and cervical cancer survival in
Instituto Nacional de Cancerología, Colombia. Colomb Med
(Cali). 2018; 49(1): 102-108.
Colomb Med. (Cali) 49(1): 9-12
 Wiesner /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Editorial
Public health and epidemiology of cancer in Colombia
Salud pública y epidemiología del cáncer en Colombia
Carolina Wiesner
Directora. Instituto Nacional de Cancerología de Colombia, Bogota, Colombia
Wiesner C. Public health and epidemiology of cancer in Colombia. Colomb Med (Cali). 2018; 49(1): 13-15. doi: 10.25100/cm.v49i1.3885
© 2018. Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.
Understanding the epidemiology of cancer has been a relatively
recent challenge for health systems of middle and low-income
countries, since the predominant pathological profiles, up to the
second half of the XX century, had been acute and communicable
diseases and therefore cancer was not given sufficient visibility1.
The epidemiology of communicable diseases requires a specific
epidemiological approach, with information that is almost in real
time, or maximum up to one year; it also requires information
based on the classification of the causal agent, with the primary
objective of controlling epidemiological outbreaks2. In contrast,
the objectives of the epidemiological surveillance of cancer are:
monitoring the behavior of different risk factors, estimating the
population risk of developing the illness, -in a designated area
and time-, as well as measuring the impact of interventions by
analyzing survival and mortality2. Since modifying the incidence
or mortality by cancer requires interventions which imply a
minimum of five years, generating information in cancer is
generally done every five years.
In high-income countries, the epidemiological transition towards
the predominance of chronic illnesses began in the XVIII
century3. Since cancer started to become a significant public
health problem in these countries, it was imperative to be able to
measure cancer incidence. Different methodologies were used for
this, such as surveys sent to physicians and passive registries that
were not effective since we found that they only reported a third
of the cases 4. This situation was very worrying because it makes it
difficult to determine the population risk as well as the possibility
to establish causal hypotheses in investigation4. It was in 1946,
when a Commission of international experts on the subject,
suggested to the World Health Organization that they establish
cancer registries with a standard methodology that was valid
and reliable. This was the most significant precedent to form the
International Association of Cancer Registries (IACR) in 19765.
Corresponding author:
Carolina Wiesner. Directora Instituto Nacional de Cancerología de Colombia.
Calle 1 No.9-85 Bogotá. Telefono +57 1 4320160. E-mail: cwiesner@cancer.gov.co
13
Since then the International Agency for the Research on Cancer
(IARC) has emphasized promoting a validated methodology such
as population-based cancer registries (RCBP)4. These registries
constitute a strategy that allows us to collect data reliably on the
incidence in a designated population which in addition allows us
to make comparisons between countries6. Frequently, we believe
that with hospital and clinic registries it is possible to obtain data
on incidence since the diagnosis of the patients that visit them is
registered on these. However, the objective of these registries is
mainly administrative and to register the clinical evaluation. For
this reason, hospital registries are not useful to generate or provide
measures on the appearance of cancer in a specific population
and environment, precisely because it is not possible to define the
population where the cases occur. Currently, 35% of all countries
in the world have high quality RCBP to report cancer incidence
and in Latin America only 22 % of countries count on these2.
Colombia was a pioneer in the development of RCBP with the
registry in Cali (RCPB-Cali), at the Universidad del Valle founded
in 1962 under the boost of Pelayo Correa, an investigator focused
on establishing causal hypotheses of stomach cancer and William
Haenszel from the National Cancer Institute of the United States7.
Based on their creation, the RCPB-Cali has generated high quality
information about cancer incidence, as the only one in the regional
context, which has a population base of such a long trajectory7-9.
The RCPB-Cali had a limited scope to demonstrate the reality
of the entire country because Colombia has great geographical,
demographical, social and cultural differences between its
regions10. Based on the expertise and trajectory of the RCBP in
Cali, Pasto generated a second RCBP. Subsequently and with the
additional support of the National Cancer Institute of Colombia
(INC-Colombia) they created the RCBP of Bucaramanga,
Barranquilla, Manizales, so that at the end of 2010 there were
 Wiesner /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
already five RCBP, four of which have been endorsed by the IARC,
and its information circulated in the “Cancer Incidence in Five
Continents”11  book. Other department registries in Antioquia,
Cesar and Huila, have worked in generating information with
difficulties in its implementation12. Based on this information
about municipal RCBP as well as information on mortality,
the INC-Colombia applies the estimation methodology of the
incidence used by the IARC as the main input to estimate cancer
incidence in the different departments and for the country13.
In addition, the RCBP allows us to generate survival information
as the most important outcome to evaluate the comparative
effectiveness of health systems regarding the control of the cancer14.
Global survival is also the most important outcome to evaluate
the effectiveness of the treatments an health system. Undoubtedly,
the comprehensive care of patients improves survival in that the
cancer treatment requires a multidisciplinary look.
This issue of Colombia Médica Magazine highlights the work
done through the methodology based on the RCBP to obtain
valid estimates of cancer incidence in a population. It is important
to highlight this trajectory because since the year 2014, cancer
incidence figures have been published in Colombia that have their
source of information in the administrative database of the health
system in Colombia (BDA-SSC for its initials in Spanish). These
publications, which demonstrate the advantage of having national
coverage, have generated controversies due to the magnitude of
the differences in cancer incidence figures when compared to
those generated by the RCBP15. The sub-registry and the non-
validation of the information generated by the BDA-SSC16  are
not useful to evaluate the population risk nor do they measure
the impact policies, or the health system have had on controlling
cancer in the country17,18.
Based on the information of the RCBP and the mortality
information from the DANE (National Administrative
Department of Statistics); the INC-Colombia generates incidence
estimates in the different departments of the country applying the
methodology used by the IARC. The TIEE (initials in Spanish for
incidence rates) for all cancers except skin cancer, were 151.5 in
men and 145.6 in women, which contrasts with the rates in the
United States of 347.0 in men and 297.4 in women.
Considering that survival rates is an outcome that must be
evaluated for the health systems not only in terms of population
but also institutionally, it shows survival data for patients treated
for the first time for breast cancer and cervical cancer in the
National Cancer Institute in the years 2007, 2010, and 2012. The
2-year survival rate of cervical cancer registered in the INC-
Colombia is similar to the one registered in the Colombian and
United States RPCC14. On the contrary, the 24-month survival
rate of breast cancer in the INC was 79.6% when for the five-year
period of 2010- 2014 in the United States it reaches 90%.
Finally, and from a public health perspective, Colombia Medica
Journal presents an analysis of oncological services carried out by
the surveillance performed by the National Cancer Institute. In
this sense, there is an analysis of services for adults as well as for
children. Regarding the first group we find that in Colombia 87.9%
of the provision of oncological services in Colombia is private in
14
nature. Private companies as well as some insurers in Colombia
open oncological services, especially for external consultation
and chemotherapy, without guaranteeing comprehensiveness
but prioritizing those services in which the use of cutting-edge
technology represents a favorable business opportunity such as
supplying expensive medications19.
Likewise, and according to the articles presented, it is worrying
that the Ministry of Health and Social Protection uses the same
instrument to activate functional units for cancer treatment in
adults and Childhood Cancer Comprehensive Care Units20. It is
clear that to guarantee the comprehensiveness for these two types
of populations there must be a differential approach in which the
fundamental variable is the frequency of the illness19. It is not the
same to guarantee the comprehensiveness for 1,312 new cases
of cancer in children under 14 years of age than for the close to
62,000 cases of cancer in adults annually.
We expect that this issue of Colombia Medica contributes to
promoting a unification of concepts relevant to the field of public
health and epidemiological surveillance of cancer considering that
it is the most important health challenge that we will have to face,
moving forward, and therefore it is important to count on analysis
instruments for health decision making.
Conflict of interest:
None declared
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of mortality and population dynamics. Am J Lifestyle Med. 2009;
3(1 Suppl):19s-26s.
2. Pineros M, Znaor A, Mery L, Bray F. A global cancer surveillance
framework within noncommunicable disease surveillance:
making the case for population-based cancer registries. Epidemiol
Rev. 2017; 39(1):161-9.
3. dos Santos SI. Cancer epidemiology: principles and methods.
Lyon: International Agency for Research on Cancer, World Health
Organization; 1999.
4. Wagner G. History of cancer registration. Jensen OM, Parkin
DM, MacLennan R, Muir RC, Skeet RG. Cancer registration:
principles and methods. Scientific Publication No. 95. IARC
Scientific Publications. Lyon: IARC, WHO; 1991.
5. Muir CS. The International Association of Cancer Registries. The
benefits of a worldwide network of tumor registries. Connecticut
med. 1985;49(11):713-7.
6. Olsen J, Basso O, Sorensen HT. What is a population-based
registry? Scandin J Public Health. 1999; 27(1):78.
7. Muñoz N, Knaul F, Lazcano E. 50 años del Registro Poblacional
de Cáncer de Cali, Colombia. Sal Publ Mexico. 2014; 56(5): 421-2.
8. Correa P. The Cali cancer registry an example for Latin America.
Colomb Med (Cali). 2012; 43(4):244-5.
 Wiesner /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
9. Bravo LE, Collazos T, Collazos P, García LS, Correa P. Trends
of cancer incidence and mortality in Cali, Colombia. 50 years
experience. Colomb Med (Cali). 2012; 43(4): 246-55.
10. Piñeros M, Murillo R. Incidencia de cáncer en Colombia
Importancia de las fuentes de información en la obtención de
cifras estimativas. Rev Colomb Cancerol. 2004; 8(1): 5-14.
11. Curado M-P, Edwards B, Shin HR, Storm H, Ferlay J, Heanue
M, et al. Cancer incidence in five continents, Volume IX. IARC
Scientific Publication No. 160. Lyon: IARC, WHO; 2007.
12. Arias NE. Registros poblacionales de cáncer: avances en
Colombia, Chile y Brasil. Facultad Nacional Salud Pública. 2013;
31(1): 127-35.
13. Pardo RC, Cendales DR. Incidencia, prevelancia y mortalidad
por cáncer en Colombia 2007-2011. Bogotá DC: Instituto Nacional
de Cancerología, Ministerio de Salud y Protección Social; 2015.
14. Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M,
Nikšić M, et al. Global surveillance of trends in cancer survival
2000–14 (CONCORD-3): analysis of individual records for
37 513 025 patients diagnosed with one of 18 cancers from
322 population-based registries in 71 countries. Lancet. 2018;
391(10125):1023-75.
15
15. Valencia O, Lopes G, Sánchez P, Acuña L, Uribe D, González
J. Incidence and prevalence of cancer in Colombia: The
methodology used matters. J Global Oncol. 2017; 4:1-7. doi:
10.1200/JGO.17.00008.
16. Benchimol EI, Manuel DG, To T, Griffiths AM, Rabeneck L,
Guttmann A. Development and use of reporting guidelines for
assessing the quality of validation studies of health administrative
data. J Clin Epidemiol. 2011;64(8):821-9.
17. de Vries E, Pardo C, Henríquez G, Piñeros M. Discrepancies in
the handling of cancer data in Colombia. Rev Colomb Cancerol.
2016; 20(1): 41-7.
18. de Vries E, Pardo C, Wiesner C. Active versus passive cancer
registry methods make the difference: case report from Colombia.
J Global Oncol. 2017; 4: 1-3. doi: 10.1200/JGO.17.00093.
19. Murillo MRH, Wiesner CC, Acosta PJA. Modelo de atención
de cáncer. Bogota: Instituto Nacional de Cancerología; 2014.
20. Ministerio de Salud y Protección Social. Resolución 1477 de 2016.
Por la cual se define el procedimiento, los estándares y los criterios
para la habilitación de las Unidades Funcionales para la Atención
Integral de Cáncer del Adulto “UFCA” y de las Unidades de Atención
de Cáncer Infantil “UACAI” y se dictan otras disposiciones. Bogota:
Ministerio de Salud y Protección Social; 2016.
Colomb Med. (Cali) 49(1): 13-15
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original article

Cancer incidence estimates and mortality for the top five cancer in Colombia, 2007-2011
Estimaciones de incidencia y mortalidad para los principales cinco tipos de cáncer en Colombia, 2007-2011

Constanza Pardo, Ricardo Cendales

Grupo de Vigilancia Epidemiológica del Cáncer, Instituto Nacional de Cancerología, Bogotá, Colombia

Pardo C, Cendales R. Cancer incidence estimates and mortality in the five first types of cancer in Colombia 2007-2011. Colomb Med (Cali). 2018; 49(1): 16-22.
Doi: 10.25100/cm.v49i1.3596.

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 6 October 2017
Revised: 15 November 2017
Accepted: 22 February 2018
Keywords:
Incidence; mortality; cancer;
epidemiology; Colombia
Palabras clave:
Incidencia; mortalidad;
cáncer; epidemiología;
Colombia
Objectives: To describe the incidence and mortality for the five main
types of cancer in Colombia, from 2007-2011.
Methods: We estimated cases and cancer incidence rates standardised
by age, based on incidence/mortality ratios; and we calculated the ob-
served deaths and mortality rates standardised by age in Colombia, both
differentiated by province, type of cancer and sex. Incidence estimates
were generated based on information from four cancer population reg-
istries (Cali, Pasto, Bucaramanga and Manizales), published in Cancer
Incidence in Five Continents, volume X, and the official mortality and
population information of the National Administrative Province of Sta-
tistics (DANE, for its initials in Spanish).
Results: The annual number of expected cases (all cancers) was 62,818
in men and women; and there were 32,653 recorded deaths. The main
incidental cancers were prostate (46.5 per 100,000 person-years) in
men, and breast (33.8 per 100,000 person-years) in women. The high-
est mortality figures were for stomach cancer in men (14.2); and breast
cancer in women (9.9).
Conclusions: The highest incidence and mortality estimates in Co-
lombia were for breast and prostate cancers, as well as a proportion of
infection-related cancers, such as stomach and cervical cancer. These
four neoplasms were responsible for more than 50% of the burden of the
disease. Only through good quality, long-duration cancer registries, can
information be obtained about the changes in incidence trends.
Objetivos: Describir la incidencia y mortalidad para los cinco principa-
les tipos de cáncer en Colombia, de 2007-2011.
Métodos: Se estimaron casos y tasas de incidencia de cáncer ajustadas
por edad a partir de razones incidencia/mortalidad y se calcularon las
muertes observadas y tasas de mortalidad ajustadas por edad en Co-
lombia, ambas diferenciadas por departamentos, tipo de cáncer y sexo.
Las estimaciones de incidencia se generaron con base en la información
de cuatro registros poblacionales de cáncer (Cali, Pasto, Bucaramanga
y Manizales), publicada en Cancer Incidence in Five Continents, volu-
men X, y la información oficial de mortalidad y población del Departa-
mento Administrativo Nacional de Estadística (DANE).
Resultados: El número anual de casos esperados (todos los cánceres)
fue 62,818 en hombres y en mujeres y se registraron 32,653 muertes.
Los principales cánceres incidentes fueron próstata (46.5 por 100,000
años-persona) en hombres y mama (33.8 por 100,000 años-persona) en
mujeres. La mortalidad más alta en hombres se presentó en estómago
(14.2) y mama en mujeres (9.9).
Conclusiones: Las estimaciones de incidencia y mortalidad más altas
en Colombia fueron para los cánceres de mama y próstata, además de
una proporción de cánceres relacionados con la infección como son el
cáncer de estómago y de cuello uterino. Estas cuatro neoplasias fueron
responsables de más del 50% de la carga de la enfermedad. Solamente
a través de los registros de cáncer de buena calidad y de larga trayec-
toria podrá tenerse información sobre el cambio en las tendencias de
incidencia..

Corresponding author:
Constanza Pardo, Grupo de Vigilancia Epidemiológica del Cáncer, Instituto
Nacional de Cancerología, Calle 1 No. 9-85, Tel.: 57 (1) 4320160 extensión
4806, Bogotá D.C., Colombia. Correo electrónico cpardo@cancer.gov.co
16
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Introduction
Colombia is considered to be a country with an intermediate
incidence of cancer within the world panorama, with rates
standardised by age estimated by the International Agency for
Research on Cancer (IARC) of 175.2 cases per 100,000 men, and
151.5 cases per 100,000 women, excluding non-melanoma skin
tumors1. For cancer, there are established methods to measure
the incidence and mortality by location at the population level:
the population-based cancer registries (RCBP, for its initials in
Spanish), which collect information on the incidence and the vital
statistics systems of the countries that provide mortality data2.
Achieving national coverage through a group of cancer registries
generates a high cost3; therefore, a viable alternative is to use
information from a few RCBP located in strategic areas and the
mortality data available at national level. The purpose is to obtain
reliable national estimates with a model that assumes that the
incidence of cancer in a region can be estimated from the number
of cancer deaths observed in that region, and from the observed
incidence/mortality ratio in a region with similar characteristics4.
In the country, there are currently five RCBP (Cali, Pasto,
Bucaramanga, Manizales and Barranquilla); these cover 12% of
the population.
The national estimate developed by the International Agency
for Research on Cancer - IARC1 is based on these two methods;
but it does not offer, at province level, the disaggregation that
is required for the country5. Due to regional variations in the
country, three studies have been carried out by the National
Cancer Institute (INC, for its initials in Spanish) under this
perspective: the magnitude of the disease, incidence and mortality
at province level6-8, information that is useful for planning human
resource training, acquisition of equipment and provision of
cancer prevention, detection, diagnosis and treatment services9. In
addition to the estimates generated by IARC, cancer information
at national level also comes from other sources that do not
match each other. On the one hand, there are the INC estimates
based on the data from the RCBP in Cali, Manizales, Pasto and
Bucaramanga; and the national system of vital statistics. The data
used from RCBP comply with international quality standards
endorsed by the IARC10. The vital statistics system provides
information on mortality, with a coverage according to data from
the World Health Organization of 98.5% for 200911, and a quality
of 92.8% according to the analysis of the certification of mortality
in Colombia, which was carried out for the 2002-2006 period12.
On the other hand, it has been necessary to have information
on the quality of cancer care, which is why passive (often
administrative) records on patient care have been created. From
these administrative records, reports13,14 which are more updated
than those from RCBP have been made, but with incidence and
mortality data with large differences and low reliability15,16.
The objective of this article is to present estimates of cancer
incidence and mortality observed in Colombia8, for the first five
cancers in men and women (prostate, stomach, breast, cervix and
colon-rectum) in the provinces, during the 2007-2011 period.
17
Materials and Methods
The geographic ordering of the country is defined by regions (two
or more provinces), provinces (set of several municipalities),
special districts, municipalities and metropolitan areas (two
or more municipalities). Based on this distribution, there were
estimates made for cancer discriminated by sex, for 25 locations,
in 27 provinces, the Capital District and a region that grouped the
provinces of Amazonas, Guainía, Guaviare, Vaupés and Vichada.
Incidence information included four RCBP, with information
from 2003-2007: Cali, Metropolitan Area of ​​Bucaramanga,
Manizales and Pasto. The mortality information was obtained
from the official mortality databases of DANE for the period
2003-2011. The population information for the same period was
obtained from the national and province estimates and projections
disaggregated by sex, area and five-year age groups of DANE17.
The incidence/mortality ratio was calculated with the groups by
cancer location, based on the tenth edition of the International
Classification of Diseases. This methodology is available in the
base publication of this manuscript8. For this article, we analyzed
five locations corresponding to stomach (C16), colon, rectum and
anus (C18-21), female breast (C50), cervix (C53), and prostate
(C61) in the provinces. The complete information for the country
is presented in Tables S1and S2.
Mortality
Cancer mortality information required some quality adjustments
in which deaths of non-residents in Colombia, deaths without sex
or age information, and those certified by persons other than a
physician were excluded8. Deaths due to other ill-defined causes
were not redistributed, nor were cancer cases or deaths from ill-
defined sites, with the exception of uterine cancer of unspecified
site (C55), which was redistributed among deaths from uterine
cancer of specified site (C53-C54), as it is recommended by the
standard methodology18. The information of the province of
residence was imputed by the province of occurrence of death,
in those cases in which this information was not available. This
allocation was not applied to the cities in which the records are
located, due to the errors that could be generated when correcting
this information in small geographical areas. No adjustment was
made for under registration of mortality.
Estimation of incident cases
A specific generalized linear model was used for each location,
which assumes that the number of cancer cases follows a Poisson
distribution and uses a logarithmic transformation as a link
function. The model considered as independent variables sex and
age group (0-14, 15-44, 45-54, 55-64 and ≤65 years), in addition to
mortality as an offset variable, and it assumes that the incidence/
mortality ratio is a constant value that is related through survival 19.
The resulting model was the following:
Ln(cancer cases) - Ln(deaths for cancer) + Bc + B sex + B2 
(age groups) + B3 (sex * age groups)
The model assumed that the incidence/mortality ratios would
be constant in the last five years. The national estimates for each
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
location were the result of the sum of estimated cases in each
province. Readers can consult the book already published to
review more details of the methodology8.
Validation of the models
The number of cases observed in each population registry was
compared with that estimated from six different models in which
the data from the registry or records not included as predictors are
assumed to be unknown, making the estimate from the remaining
records. Each of the first five models was weighed based on the
square root of the population of each record; the sixth model
corresponds to estimated data without considering weighing. The
accurate fit of the models was not evaluated because they were all
saturated.
To evaluate the statistical validity of each model, the difference
between the number of cases detected by the registry and the
number of cases estimated by the model was calculated; based on
these differences, the sum of squared errors was calculated. Table
1 shows the model used for the estimations, which was generated
from the weighted model with combined information from the
Cali, Pasto, Manizales and Bucaramanga cancer registries, which
obtained the lowest values of the sum of squared errors ​​- SSE.
Crude rates (CR) were calculated for cancer incidence and
mortality per 100,000 person-years for each of the cancer sites,
according to sex and provinces of the country. The CR were
standardised by age (ASR) using the direct method with the world
reference population (SEGI population).
Results
Incidence of cancer
The annual national estimate of incident cases for 2007-2011 was
62,818 cases of cancer, 29,734 in men and 33,084 in women. Age-
standardised cancer incidence rates (ASIR) per 100,000, in men
were 151.5 and 145.6 in women (Table S1). Women had a lower
incidence ratio than men in stomach cancer (M: F: 1.8: 1), and a
similar incidence ratio in colorectal cancer (M: F; 1: 1).
In men, the highest ASIR were for prostate (46.5), followed by
stomach (18.5) and colorectal cancer (12.2). Among women, the
highest ASIR were for breast (33.8), cervix (19.3), colorectal (12.3)
and stomach (10.3). The incidence of breast cancer was twice as
high as cervical cancer, and it accounted for 23.0% of all cancer
cases in women and 37.6% together with cervix. The five cancers
(prostate, breast, cervix, stomach and colorectal) are responsible
for more than 50% of new cancer cases in Colombia (Table
Table 1. Sum of the differences between the observed cancer cases
and the estimated cases squared (sum of squared errors - SSE).
SSE according to the RPC
included in the model
Men Women
SSE RPCC 229,603 230,699
SSE RPCC, RPCB 113,099 200,271
SSE RPCC, RPCP 193,892 182,835
SSE RPCC, RPCM 190,927 173,383
SSE RPCC, RPCP, RPCM, RPCB 113,296 142,270
SSE RPCC, RPCP, RPCM, RPCB* 126,325 145,327
* Not weighted RPC: Population Registry of Cancer;
RPCC: Population Registry of Cancer, Cali;
RPCB: Population Registry of Cancer, Bucaramanga;
RPCP: Population Registry of Cancer, Pasto;
RPCM: Population Registry of Cancer, Manizales.
18
2). Table S1shows the totality of locations in greater detail.
Prostate cancer corresponded to 29.8% of cancer cases among
men; it presented the highest ASIR in the provinces of San Andrés
and Providencia (90.0), Cesar (60.8), Atlántico (60.4) and Valle
del Cauca (59.8) Similarly, breast cancer presented the highest
ASIR in Valle del Cauca (43.5), Atlántico (42.8) and San Andrés y
Providencia (41.9). Provinces such as Arauca (38.7), Meta (37.6)
and Caquetá (30.8) had the highest incidence rates for cervical
cancer (Fig. 1a-e).
Age-standardised cancer incidence rates for stomach in men
predominated in Quindío (32.1), Huila (30.2) and Cauca (26.8);
in women, they were higher in Cauca (16.9), Norte de Santander
(15.9) and Quindío (15.6). In contrast, the Caribbean region
presented the lowest ASIR, in a range of 3.3 -10.7 in men and
2.4 - 6.0 in women (Table 2S). ASIR for colorectal cancer were
very similar for both sexes. In men, Quindío (18.3), Bogotá (18.0)
and Risaralda (16.0) predominated; in women, Quindío (18.5),
Risaralda (16.6) and Caldas (16.2).
Table S2 shows the highest province rates for all cancers; 55%
of cancers occurred in five provinces (Antioquia, Bogotá,
Cundinamarca, Santander and Valle del Cauca). In men, the
largest ASIR were in Quindío (195.5), Risaralda (182.4), Valle
del Cauca (179.6) and Antioquia (173.1); in women, Quindío
(193.3), Caldas (170.4), Risaralda (168.6) and Meta (167.9). The
incidence of cancer in Bogotá and nine other provinces was above
the national average (151.5). Men had a lower incidence ratio than
women only in the provinces of Tolima (M: F; 0.9: 1) and Nariño
(M: F; 0.9: 1).
Mortality from cancer
Annual cancer deaths in men and women were 32,653; 16,081 in
men and 16,572 in women, with an age-standardised mortality
rate (ASMR) of 82.3 in men and 73.2 in women (Table S1). The
incidence / mortality ratio was 1.8 in men and 2.0 in women.
Cancers in men with the highest ASMR occurred in stomach
(14.2), prostate (12.6), and colorectal (6.0). In women, breast
(9.9), cervix (8.2) and colorectal (6.1) (Table 2).
Age-standardised mortality rate for provinces showed notable
differences. 56.0% of the deaths occurred in the provinces of
Antioquia, Bogotá, Cundinamarca, Santander and Valle del
Cauca. The largest ASMR for men were found in Quindío (111.2),
Risaralda (103.2), Antioquia (99.7) and Valle del Cauca (96.8); for
women, Quindío (91.5), Caldas (85.5), Risaralda (91.0) and Meta
(86.2) (Table S2).
In men, the provinces with the highest ASMR for stomach were
in Quindío (24.4), Huila (23.2) and Cauca (20.5). In women,
the highest were in Cauca (12.8), Norte de Santander (12.1) and
Total Quindío (11.8). Prostate cancer predominated in San Andrés
460,302 (25.5), Atlántico and Valle del Cauca, both with ASMR of 16.6.
313,370 Mortality per breast cancer represented 13.4% among all cancer
376,727 deaths in women; the highest rates presented in San Andrés
364,311
255,566
(13.3), Valle del Cauca (12.7) and Atlántico (12.5). Provinces such
271,652 as Meta (16.5), Arauca (15.9) and Caquetá (13.2) also had the
highest mortality rates from cervical cancer. For colon-rectum,
the highest mortality rates occurred in Bogotá and the Old Caldas
region (Fig. 1 a-e).
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Table 2. Cancer incidence and mortality, five first locations, Colombia, 2007-2011.
Characteristics Stomach Colorectal Breast Cervix Prostate
C16 C18-C20 C50 C53 C61
5,955 5,185 7,627 4,462 8,872
Incident cases (year) Men 3,613 2,401 … … 8,872
Women 2,342 2,784 7,627 4,462 …
16.3 10.8 … … 40.0
Rates (men)
ASR 18.5 12.2 … … 46.5
10.3 12.2 33.5 19.6 …
Rates (women)
ASR 10.3 12.3 33.8 19.3 …
4,537 2,544 2,226 1,861 2,416
Observed Men 2,767 1,168 … … 2,416
deaths (year)
Women 1,770 1,376 2,226 1,861 …
12.5 5.3 … … 10.9
Rates (Men)
ASR 14.2 6.0 … … 12.6
Rates (Women) CR 7.8 6.0 9.8 8.2 …

AAR ASR 7.8 6.1 9.9 8.2 …

CR, crude rate
ASR, age-standardised rate (per 100,000 years - person)

Discussion In general, for Colombia, standardized rates of both incidence and

According to these estimates, the five main locations of incidental
cancers in Colombia are stomach, colorectal, breast, cervical,
and prostate cancer. This is the third time that this exercise has
been done for Colombia by provinces8, with the incorporation of
the recommendations made in past editions. For the first time,
data from four cancer registries, Cali, Pasto, Manizales and the
Metropolitan Area of ​​Bucaramanga are included in the estimation
models, in addition to the official mortality data registered for
Colombia, with 92.8% of quality in the certification. The importance
of this incorporation lies in the fact that the current estimates reflect
the diversity in the risk profiles for cancer incidence more for each
region. A relevant factor is the quality of the information produced
by the records included in the model, because they already complied
with international quality standards2.
The differences in the numbers incidence estimated by Globocan
2012 are related to the model selected, which includes data from
cancer registries in South America and also for the use of estimated
mortality in the country. Estimating the incidence/mortality
ratio based on the last available year of the registry generated
very volatile figures, so for these locations the information from
the five-year period was used. However, for breast and prostate
cancer, Globocan 2012 considered that this assumption would not
be met with the relative recent introduction of screening for these
pathologies, with a fluctuating result in the incidence/mortality
ratios for these pathologies. This way, Globocan 2012 based the
incidence/mortality ratio only on the result of the most recent
year of reporting of population registries20. On the other hand,
the estimated annual figures for 2007-2011 were lower when
compared with the annual figures of incidence estimated in 2002-
2006, because in this study the correction for under-registration
of mortality was not incorporated21.
When contrasting the incidence and mortality information
generated in Colombia using other sources13,14, a great difference in
figures is evident, both in absolute numbers and rates. Probably this
discrepancy is due to the different methods used in the collection,
processing and analysis of the data, sometimes resulting in less than
50% of the real number of patients present in the country15.
mortality were lower than in countries such as the United States,
Australia, New Zealand and countries of South America22. In turn,
these five types of cancer were also the main incidental cancers
and the leading cause of mortality in Central and South America.
However, it is highlighted that stomach cancer and cervical cancer
have much higher rates than in other Latin America countries,
such as Brazil, Argentina and Mexico, among others23.
The first three locations with the highest incidence (of cancer)
in men were prostate, stomach and colon-rectum; and breast,
cervix and colon-rectum in women. It is noteworthy that all the
five main locations are characterized by having surgical treatment
as a fundamental element in the comprehensive management of
the disease. By geographical location, these cancers occur in five
of the main provinces of Colombia, such as Antioquia, Bogotá,
Cundinamarca, Santander and Valle del Cauca, which have
the largest population. This situation implies in absolute terms
(frequencies), the basis to make decisions about the number
of health institutions needed in the different areas. In fact, this
is corroborated in the panorama of oncology services enabled,
mainly in surgery, and in these provinces of the country24.
The incidence and mortality from stomach cancer is one of the
first causes in the country, and this behavior is similar in Latin
American countries such as Argentina, Brazil, Chile and Costa
Rica23. It is highlighted that despite the behavior, the tendency has
been to decrease in recent decades25,26. This decrease is attributed to
the improvement in hygiene conditions and food preservation24,27.
In gastric cancer, the smallest difference between mortality rates
versus incidence rates occurs because it is a highly fatal cancer.
Colorectal cancer corresponds to 8.3% of the incident cases in
the country, and its behavior in other Latin American countries
turns out to be much higher than in Colombia, even with higher
rates than for stomach cancer, in countries such as the United
States, Brazil and Argentina23. Obesity is one of its risk factors,
and its behavior in the country was of high figures of overweight
according to the survey of nutritional status (ENSIN, for its
Spanish acronym) from 2010. The highest prevalence of excess
weight occurred in urban areas (52.5%) and in women (84.1%),
which may explain the behavior of the rates.

19
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

1b. Colorectal Age-Standarized Rate x 100,000 person-year

1a. Stomach Age-Standarized Rate x 100,000 person-year
25 20 15 10 5 0 5 10 15 20 25
40 30 20 10 0 10 20
Quindío 32.1 15.6 Quindío 18.3 18.5
24.4 11.8 8.4 8.5
Huila 30.2 13.2 Bogotá 18.0 15.9
23.2 10.2 9.0 7.8
Cauca 26.8 16.9 Risaralda 16.0 16.6
20.5 12.8 7.7 8.1
Nariño 26.1 14.8 Caldas 15.9 16.2
20.2 11.1 7.6 8.0
Norte de Santander 25.0 15.9 Valle del Cauca 14.9 15.3
19.4 12.1 7.3 7.5
Boyacá 24.7 13.1 Meta 14.0 15.0
19.0 10.0 7.1 7.6
Tolima 24.7 12.1 Santander 13.8 12.5
19.0 9.0 6.8 6.1
Caldas 24.5 12.2 Antioquia 13.5 13.5
18.6 9.2 6.7 6.7
Risaralda 24.5 13.4 Cundinamarca 13.5 9.9
18.8 10.2 6.6 4.9
Casanare 23.0 12.6 Tolima 11.9 13.3
17.3 8.7 5.8 6.7
Colombia 18.5 10.3
Colombia 12.2 12.3
14.2 7.8 6.0 6.1

Men Incidence Mortality Women Men Incidence Mortality Women

Age-Standarized Rate x 100,000 person-year Age-Standarized Rate x 100,000 person-year

1c. Breast
0 5 10 15 20 25 30 35 40 45 50 1d. Cervix Uteri 0 5 10 15 20 25 30 35 40 45

Valle del Cauca 43.5 Arauca 38.7

12.7 15.9
Atlántico 42.8
12.5 Meta 37.6
16.5
San Andrés 41.9 Caquetá 30.8
13.3 13.2
Arauca 39.9
10.7 Casanare 30.6
13.2
Quindío 38.9
11.5 Tolima 28.2
11.5
Caldas 38.4
11.2 Cesar 28.1
11.6
Bogotá 37.2
11.0 Quindío 26.7
10.4
Huila 36.9
10.6 Grupo Amazonas 25.9
11.7
Risaralda 36.4
10.9 Norte de Santander 25.5
10.4
Meta 36.4
10.8 Incidence Magdalena 23.9
10.2
Incidence
Colombia 33.8
9.9
Mortality
Colombia 19.3
8.2 Mortality

Age-Standarized Rate x 100,000 person-year

1e. Prostate
0 10 20 30 40 50 60 70 80 90 100

San Andrés 90.0

25.5
Cesar 60.8
16.0
Atlántico 60.4
16.6
Valle del Cauca 59.8
16.6
Arauca 58.3
12.8
Casanare 54.4
14.6
Magdalena 53.0
14.4
Chocó 52.1
13.1
Meta 50.6
12.9
Norte de Santander 50.0
13.6 Incidence
Colombia 46.5
12.6
Mortality

Figure 1(a-e). Cancer incidence and mortality, according to provinces, five main locations, Colombia, 2007-2011.

20
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
In relation to prostate cancer, it is the first diagnosis most
frequent in men, whose incidence rate (46.5) is below the rate
for South America (60.1), but above the rate for Central America
(28.4)23. In addition, it is the second cause of cancer mortality in
Colombia, with the highest mortality rates in the coastal region
and Valle del Cauca. The wide incidence ranges may be due to
screening programs (prostate-specific antigen tests - PSA), to the
availability of treatment services in the different regions since
these provinces coincide with those with the highest percentage
of Afro-Colombian population.
Something similar occurs with regional differences in breast
cancer incidence rates, provinces with a large proportion of
Afro-Colombian population; as well as being influenced by the
availability of early detection services; and reproductive and
hormonal risk associated factors, such as overweight or obesity,
post-menopause, the use of menopausal hormone therapy,
physical inactivity and alcohol consumption28,29.
A downward trend in cervical cancer has also been found , with the
26
highest rates in provinces of the Orinoquía region. This particular
case may be associated with low access in the diagnostic process
for this population. According to vaccination campaigns against
HPV, coverage in 2012 was above 95% in the whole country, with
the exception of Caquetá (82.2%), Vichada (74.4%) and Putumayo
(86.1%) for the first phase; Guainía, Vaupés and Caquetá, among
others, for the second phase30. It is necessary to continue with the
coverage of screening programs and to comply with vaccination
coverage against human papilloma virus (HPV), whose prevalence
is 16% in Latin America, in order to achieve early detection and
elimination of precancerous lesions, and of HPV31.
The limitations of this study include the fact that only 12% of the
population in Colombia is covered by four high-quality RCBP,
and the estimates were made according to the latest available
information from the RCBP (quinquennium). The processes of
completeness (thoroughness) and validity of the data takes longer,
which generates delays in the reports of population incidence and
therefore in the national estimates.
Conclusions
Colombia, classified as a middle income country, presented
higher estimates in cancers such as breast, prostate, as well as a
proportion of cancers related to infection, such as stomach and
cervical cancer. Estimates from RCBP strategically located within
a country constitute an effective option that is currently used by
different countries such as Brazil, Colombia, Turkey and China,
among others2. However, RCBP as a standard strategy for cancer
surveillance, burden measurement and evaluation of the impact of
the disease32,33 present the difficulty of having a national coverage,
a situation that lies in viability and long-term sustainability3,34.
Population registries of cancer and vital statistics - DANE, provide
sufficient information to produce estimates at the national and
province levels. It would be desirable to improve the quality of
some existing cancer registries in other areas of the country, so
they can be included in the estimates, and to establish some other
registries, in order to expand the current coverage (12%). Only
through RCBP of good quality and long trajectory can information
be obtained about changes in the incidence trends.
21
Acknowledgements:
The authors thank Dr. Esther de Vries for reviewing the
manuscript and for her valuable comments. This article is part of
the publications “Incidence, mortality and prevalence of cancer
in Colombia 2007-2011” - http://www.cancer.gov.co/files/libros/
archivos/incidencia1.pdf “Incidence, mortality and prevalence
of cancer in Colombia 2007-2011, attached tables “- http://www.
cancer.gov.co/files/libros/archivos/incidencia2.pdf
Conflict of interest: 
The authors declare no conflicts of interest for this study
Funding:
The work was carried out with resources administered by the
National Cancer Institute (Epidemiological Cancer Surveillance
Program
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Colomb Med. (Cali) 49(1): 16-22
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original article

Reliable information for cancer control in Cali, Colombia

Información fiable para el control del cáncer en Cali, Colombia

Luis Eduardo Bravo1,2, Luz Stella García1, Paola Collazos1, Edwin Carrascal1,2, Oscar Ramírez1,3,4, Tito Collazos1, Armando Cortés2,
Marcela Nuñez1, Erquinovaldo Millan5

1
Registro Poblacional de Cáncer de Cali. Cali, Colombia
2
Departamento de Patología, Facultad de Salud, Universidad del Valle, Cali, Colombia.
3
Fundación POHEMA. Cali, Colombia
4
Sistema de Vigilancia Epidemiologica de Cáncer Pediátrico (VIGICANCER), Cali, Colombia.
5
Secretaria de Salud Pública Municipal de Cali, Cali, Colombia.

Bravo LE, García LS, Collazos P, Carrascal E, Ramírez O, Cortés A, Nuñez M, Millán E. Reliable nformation for cancer control in Cali, Colombia. Colomb Med (Cali). 2018;
49(1): 23-34. doi: 10.25100/cm.v49i1.3689

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

History article Abstract Resumen

Received: 13 December 2017 Background: The Cali Population Cancer Registry (RPCC) has been in
Revised: 20 January 2018 continuous operation since 1962 with the objective of producing valid
Accepted: 13 February 2018
statistics on the incidence of cancer, its patterns, trends and survival rates.
Keywords: Methods: During the period 2008-2012, 23,046 new cases were
Cancer registry, incidence, registered and during 2011-2015 there were 12,761 cancer deaths. The
mortality, survival, methods, trend of the rates was described with the APC average annual change
Cali, Colombia rate and with the Joinpoint analysis. We analyzed the individual data
of 38,671 adults (15-99 years) diagnosed with cancer between 1995-
Palabras clave:
2009, and we calculated the standardized net survival by age for the
Registro de cáncer, incidencia, 14 most common cancer body sites, using the Pohar-Perme method.
mortalidad, supervivencia,
métodos, Cali, Colombia Results: Prostate and breast cancer were the first cause of cancer
morbidity. The incidence rates in these susceptible to early detection,
tumors stabilized after decades of growth, while an increase in the
incidence of colon cancer and papillary thyroid carcinoma was
observed. The incidence rates of cervical and stomach cancer,
conditions related to infectious agents, decreased, although the
number of absolute cases increased, due to the growth and aging
of the population. Gastric cancer was responsible for the highest
number of cancer deaths. The types of cancer related to tobacco
consumption (lung, oral cavity, esophagus, pancreas, urinary
bladder) showed low numbers and a tendency to decrease. During
the period 2000-2004, the 5-year net survival improved for cancers
of the breast, cervix, prostate, melanoma and thyroid, although in
the period 2005-2009 a stagnation was observed. In stomach, liver
and lung cancer, the 5-year net survival was less than 15%. The
5-year overall survival in children was 51.0% (95% CI: 47.5, 54.3)
and in adolescents 44.6% (95% CI: 36.0, 52.8).
Comment: RPCC has been an advisor to the Colombian government
in the evaluation of CPRs in the country and its data have contributed
significantly to different aspects of cancer control in Colombia.
Corresponding author:
Luis Eduardo Bravo, Director Registro Poblacional de Cáncer de Cali. Calle 4B 31-00
Oficina 4003, Edificio 116, Cali, Colombia. E-mail: luis.bravo@correounivalle.edu.co.
Antecedentes: El Registro Poblacional de Cáncer de Cali (RPCC) está en
operación continua desde 1962 con el objetivo de producir estadísticas
válidas sobre la incidencia de cáncer, sus patrones, tendencias y
supervivencia.
Métodos: Durante el periodo 2008-2012, se registraron 23,046 casos
nuevos y durante 2011-2015 se registraron 12,761 defunciones por
cáncer. La tendencia de las tasas se describió con el porcentaje de cambio
medio anual APC y con el análisis de Joinpoint. Se analizaron los datos
individuales de 38,671 adultos (15-99 años) con diagnóstico de cáncer
entre 1995-2009, y se calculó la supervivencia neta estandarizada por
edad para las 14 localizaciones más comunes de cáncer, con el método
de Pohar-Perme.
Resultados: Próstata y mama fueron la primera causa de morbilidad por
cáncer. Las tasas de incidencia en estos tumores susceptibles de detección
temprana se estabilizaron tras décadas de crecimiento, mientras que se
observó un incremento de la incidencia de cáncer de colon y carcinoma
papilar de tiroides. Las tasas de incidencia de cáncer de cuello uterino y
estómago, afecciones relacionados con agentes infecciosos, disminuyeron,
aunque el número de los casos absolutos aumentó, debido al crecimiento
y envejecimiento de la población. El cáncer gástrico fue responsable del
mayor número de muertes por cáncer. Los tipos de cáncer relacionados
con el consumo de tabaco (pulmón, cavidad oral, esófago, páncreas, vejiga
urinaria) mostraron cifras bajas y con tendencia al descenso. Durante
el periodo 2000-2004, la supervivencia neta a 5 años mejoró para los
cánceres de mama, cuello uterino, próstata, melanoma y tiroides, aunque
en el periodo 2005-2009 se observó un estancamiento. En cáncer de
estómago, hígado y pulmón, la supervivencia neta a 5 años fue inferior al
15%. La supervivencia global a 5 años en niños fue de 51.0% (IC 95%: 47.5,
54.3) y en adolescentes de 44.6% (IC 95%: 36.0, 52.8).
Comentario: El RPCC ha sido asesor del gobierno colombiano en la
evaluación de RPCs en el país y sus datos han contribuido significativamente
a diferentes aspectos del control del cáncer en Colombia.

23
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Introduction
Comprehensive cancer control is a strategic approach that brings
together the main associations and organizations of a community
to prevent or minimize its impact and to develop a plan to reduce
the number of citizens who become ill or die from cancer. The
plans are specific, based on an analysis of the cancer situation in
each country1. It is essential that the information on incidence,
mortality and survival be of high quality because it will help
monitor and evaluate the programs. Population-based cancer
registries (RCPobs) represent the gold standard for providing
cancer incidence and survival figures in a region and are a key
element in cancer control because they provide indicators for
planning and evaluating cancer control activities and carrying out
cancer research2. The information disclosed by these information
systems in Colombia indicates that cancer is a public health
problem that causes 63,000 new cases and 33,000 deaths each year3.
To face this threat, the Colombian government has formulated a
Ten-Year Plan for Cancer Control in Colombia (PDCC)4 focusing
on activities to control and reduce mortality from cancer of cervix,
stomach, prostate, breast, colon and acute pediatric leukemias.
Colombia lacks an RCPobs with national coverage and for several
decades the only source of valid cancer incidence information for
the country was the Cali Population Registry of Cali (RPCC)5.
Now it has three additional regional RCPobs that provide
quality cancer incidence information in Pasto6, Manizales7  and
Bucaramanga8; and two new ones in the process of consolidation
in Barranquilla9 and Medellín10. The coverage of these six regional
RCBPs is less than 12.9% of the Colombian population. To
overcome this limitation, health authorities use GLOBOCAN
methods to make national and regional cancer incidence estimates
based on mortality information11. The incidence/mortality ratio
of the period of interest of each regional RCPob is incorporated
into a mathematical model that uses this information and the
mortality observed in each department as inputs to estimate
the departmental and national incidence3,11. The validity of the
estimates depends on the quality of the information and also on
the accurate quality of the certification of general mortality and
cancer in Colombia and the coverage of the certification is close
to 100%12.
In this article, the Cali Population Registry discloses the most
recent cancer statistics in Cali, Colombia, for incidence and
mortality rates standardized by age (ASR) for all cancers for the
periods 2008-2012 and 2008-2015, respectively; and the 5-year net
survival estimates standardized by age for the 14 most common
cancer sites from 1995 to 2009. Estimating the incidence of
cancer in Colombia and creating some of the baseline indicators
of the current PDCC in the city is a contribution made by the
Universidad del Valle to the health authorities.
Materials and Methods
Population and registration area
Cali is the third largest city in Colombia, capital of the Department
of Valle del Cauca. According to the 2005 census and according
to the projections of the DANE13, the estimated population for
2010 was 2.3 million inhabitants. 52% are females, and 26.2%
self-identify as belonging to the black ethnic group14. The life
expectancy at birth is 73.1 years for men, and 78.5 years for
24
females15. The infrastructure for cancer care includes 165 oncology
functioning services 16, these services are in the urban area where
95% of the population resides in an area of ​​approximately 110
km2 that corresponds to 20% of the extension of the municipality
of Cali (503 km2).
Incidence and mortality information
Information on the incidence of cancer was obtained from the
database of the RPCC (2008-2012) and information on general
mortality was obtained in the Municipal Public Health Secretary
of Cali (2006-2015). Details on the history, objectives, logistics
and coverage of the RPCC have been previously described5,17.
This same issue of Colombian Medical describes in detail the
procedures and methods for estimating incidence, mortality
and survival in adults18. In summary, the RPCC was established
in 1962, it is a population-based cancer registry which provides
continuous information on new cases of all types of cancer in
permanent residents of Cali through active search and notification.
Implementation of a childhood cancer outcomes surveillance
system (VIGICANCER) within Cali’s population-based cancer
registry was carried-out in 2009; methodological details have been
published recently19,20. Briefly, children and adolescents (<19 years
of age) with new diagnosis of cancer and treated in a pediatric
oncology unit of the city, are registered by the system and included
in an active follow-up. VIGICANCER includes both children living
in the city as well as children from other Colombian municipalities
and provinces but treated in Cali. Vital status, relapse, treatment
abandonment, and second neoplasms are the primary outcomes.
Results
1. New cases of cancer (incidence)
In the quinquennium 2008-2012, 23,046 new cases of cancer were
diagnosed among the permanent residents of Cali, for an average
of 4,500 cases per year; 55% (12,613) occurred in females and the
sex ratio was 1:2. The incidence rates standardized by age for all
cancer sites per 100,000 person-years were 204.6 in men; and 185.1
in females. In the absence of other causes of death, the cumulative
risk of developing cancer before reaching the age of 75 was 23.8%
and 20.5% in males and females in Cali.
Cancer incidence rates per 100,000 person-year by sex and cancer
location are shown in  Table 1. In men, the five primary sites of
primary cancer were prostate (ASR: 59.7), stomach (ASR: 20.2),
colorectal (ASR: 16.2), lung (ASR: 14.5), and lymphomas (ASR:
11.3). Together they constituted 58.8% of all new cancer cases
diagnosed between 2008 and 2012. Prostate cancer accounted for
28.2% of all incident cases, (n: 2,937).
In females, the most frequent locations for cancer according to
their ASR were in descending order: breast (44.3), cervix (15.3),
colorectal (14.0), thyroid (13.2), and stomach (10.7). These
locations together accounted for 52.9% of all new cases of cancer
diagnosed during the five-year period. Breast cancer alone
accounted for 23.6% of incident cases (n: 2,972).
2. Mortality from cancer
Table 2  shows cancer deaths that occurred in Cali in two
quinquennial periods; 2006-2010 and 2011-2015. During this
decade there were 122,014 deaths, (56.8% in males and 43.2% in
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Table 1. Cali, Colombia. Incidence rates standardized by age (World Population) per 100,000 person-year and the annual percentage
change (APC) by sex during the period 2008-2012
Male Female Male Female Code
Site n ASR n ASR APC 95% IC APC 95% IC ICD 10
Oral cavity and pharynx 279 5.4 233 3.4 -1.2* -1.7;-0.7 -1.1* -1.6;-0.5 C00 14
Oesophagus 90 1.7 72 1.0 -1.3* -2.1;-0.5 C15
Stomach 1,041 20.2 769 10.7 -1.9* -2.1;-1.7 -1.9* -2.1;-1.6 C16
Small intestine 39 0.7 37 0.5 C17
Colon and Rectum 831 16.2 996 1.4 2.4* 2.0;2.7 1.9* 1.5;2.3 C18 20
Anus 48 1.0 126 1.9 C21
Liver 249 5.0 218 3.1 1.7* 0.9;2.4 0.4 -0.5;1.2 C22
Gallbladder 120 2.4 264 3.7 -1.3* -1.9;-0.6 -1.8* -2.4;-1.2 C23 24
Pancreas 222 4.4 257 3.6 0.0 -0.5;0.5 C25
Nose, sinuses, etc. 38 0.7 18 0.3 C30 31
Larynx 202 4.0 37 0.6 -1.1* -1.6;-0.6 C32
Trachea, bronchi and lung 731 14.5 585 8.2 -0.6* -1.1;-0.1 0.5* 0.0;1.1 C33 34. C38 39
Bone 75 1.4 84 1.3 0.8 -0.1;1.6 0.1 -0.9;1.1 C40 41
Connective tissue 135 2.6 134 2.1 0.4 -0.2;1.0 C47 49
Mesothelioma 9 0.2 7 0.1 C45
Kaposi sarcoma 92 1.6 10 0.1 C46
Skin melanoma 145 2.8 179 2.6 1.1* 0.5;1.7 C43
Other skin 28 0.5 41 0.6 C44
Breast 26 0.5 2,972 44.3 1.4* 1.1;1.6 C50
Vulva 60 0.8 -1.6* -2.4;-0.8 C51
Vagina 44 0.7 C52
Uterus unspecified 37 0.5 C55
Uterine cervix 1,037 15.3 -3.0* -3.2;-2.8 C53
Corpus uteri 347 5.3 0.3 -0.1;0.7 C54
Ovary 513 7.7 -0.1 -0.5;0.2 C56
Other females genital organs 22 0.4 C57 58
Penis 74 1.3 C60
Prostate 2,937 59.7 3.0* 2.5;3.5 C61
Testicle 154 2.6 1.7* 1.0;2.5 C62
Other male genital organs 8 0.1 C63
Kidney 250 5.1 209 3.2 2.8* 2.1;3.4 2.3* 1.7;2.9 C64 66
Bladder 319 6.2 121 1.6 -0.7* -1.1;-0.3 -1.2* -1.7;-0.6 C67
Other urinary organs 3 0.0 4 0.1 C68
Eye 48 0.9 37 0.6 C69
Central Nervous System 271 5.2 269 4.3 1.2* 0.5;1.9 2.3* 1.2;3.4 C70 72
Thyroid 173 3.2 893 13.2 0.7 -0.1;1.5 2.6* 2.1;3.1 C73
Other endocrine 25 0.5 21 0.4 C74 75
Hodgkin's disease 91 1.7 63 1.0 -1.6* -2.2;-0.9 -0.6 -1.4;0.2 C81
Non-Hodgkin lymphoma 502 9.6 511 7,5 2.3* 1.7;2.8 2.1* 1.6;2.7 C82 85. 96
Multiple myeloma 156 3.1 142 2,1 C90
Lymphocytic leukaemia 205 4.0 211 3,6 2.1* 1.6;2.7 C91
Myeloid and monocytic leukaemia 172 3.3 173 2,6 0.0 -0.6;0.7 1.1* 0.5;1.6 C92 94
Non-specific leukaemia 53 1.0 53 0,7 C95
Unknown primary site 581 11.3 797 11,3 -0.3 -0.7;0.1 -0.8* -1.2;-0.4 **
All the sites 10,433 204.6 12,613 185,1 0.6* 0.4;0.8 -0.1 -0.2;0.1 C00 96
All sites * 10,405 204.1 12,572 184,5 0.6* 0.4;0.8 -0.1 -0.2;0.1 C00 43.45 96
** C26.39.48.76.80 - CIE O: 998_ / 3
Number of cases (n); Standardized incidence rate by age (ASR, by its acronym in English).
APC: For its acronym in English Annual Percent Change. APC is calculated for period 1962-2012
* All sites excluding non-melanoma skin cancer

females). Overall mortality from cancer corresponded to 19.6%
(23,873 deaths) of all deaths in that period and the number of
deaths from this cause was greater among females (53.0%, 12,663)
than among males (47.0%, 11,219). For the analysis of cancer
mortality, emphasis was placed on the results of the quinquennium
2011-2015.
Cancer was the third cause of death in Cali after mortality due to
cardiovascular diseases (26.0%) and unintentional or intentional
injuries (20.1%).
In contrast to the number of deaths, standardized cancer mortality
rates for all combined locations per 100,000 person-years were
higher among males (107.0) than among females (85.9). Cancer of
stomach, lung, colorectal, breast and prostate were the main causes
of cancer-related death, together they represent approximately
half of all cancer deaths (47.9%).
Based on mortality rates standardized by age, prostate cancer (ASR:
17.4), was the leading cause of death among tumors in males in the
five-year period 2011-2015, followed by cancer of stomach (ASR:
14.4), lung (ASR: 14.4), colorectal (ASR: 10.2) and lymphomas
(ASR: 6.0). Breast cancer was the leading cause of death in females
(ASR: 13.8), followed by cancer of stomach (ASR: 8.2), colorectal
(ASR: 7.5), lung (ASR: 7.3) and cervix (ASR: 6.5).

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Table 2. Cali, Colombia. Mortality rates standardized by age (World Population) per 100,000 person-year and the annual percentage
change (APC) by sex during the period 2006-2015
2006-2010 2011-2015 APC
Code
Site Male Female Male Female Male Female
n ASR n ASR n ASR n ASR APC 95% IC APC 95% IC ICD 10
Mouth and oropharynx 90 1.9 82 1.2 115 2.0 104 1.3 -2.7* (-3.5 ; -1.9) 0.0 (-1.2 ; 1.2) C00-14
Oesophagus 91 1.9 54 0.8 95 1.7 52 0.7 -3.5* (-4.4 ; -2.5) -3.9* (-5.1 ; -2.7) C15
Stomach 801 16.6 607 9.0 807 14.4 659 8.2 -2.3* (-2.7 ; -2.0) -2.5* (-2.9 ; -2.1) C16
Colon and rectum 421 8.6 483 7.1 570 10.2 607 7.5 2.0* (1.4 ; 2.7) 0.4 (-0.2 ; 1.1) C18-21
Liver 305 6.4 311 4.7 317 5.7 372 4.5 -0.2 (-0.8 ; 0.5) -1.5* (-2.1 ; -0.8) C22
Pancreas 180 3.8 235 3.5 252 4.5 300 3.7 -0.6 (-1.3 ; 0.2) -1.2* (-2 ; -0.5) C25
Lung 714 14.8 531 8.0 799 14.4 602 7.3 -1.8* (-2.2 ; -1.4) -0.8* (-1.3 ; -0.3) C33-34
Skin melanoma 105 2.1 102 1.4 152 2.7 126 1.6 2.2* (1.2 ; 3.2) 1.2 (-0.1 ; 2.5) C43-44
Breast 8 0.2 904 14.1 7 0.1 1,055 13.8 0.1 (-0.4 ; 0.6) C50
Cervix uteri 471 7.4 487 6.5 -3.9* (-4.3 ; -3.5) C53
Corpus uteri 115 1.7 138 1.9 -2.3* (-3.5 ; -1.1) C54-C55
Ovary 297 4.7 302 4.0 -0.6 (-1.5 ; 0.3) C56
Prostate 847 16.7 1,012 17.4 -0.1 (-0.5 ; 0.4) C61
Bladder 100 2.0 58 0.8 113 2.0 75 0.9 -1.2* (-2.4 ; -0.1) -2.5* (-3.9 ; -1.1) C67
Lymphoma 256 5.3 237 3.8 330 6.0 290 3.7 -0.8* (-1.5 ; 0.0) -1.1* (-1.9 ; -0.3) C81-C90,C96
Leukaemia 259 5.1 286 4.6 270 4.6 246 3.5 -0.6 (-1.2 ; 0.0) -0.6 (-1.5 ; 0.3) C91-95
Other sites 1,003 20.6 1,159 17.8 1,191 2.1 1,316 1.7 -0.7* (-1.1 ; -0.3) -1.2* (-1.6 ; -0.9) **
All sites 5,180 10.6 5,932 90.7 6,030 10.7 6,731 85.9 -0.9* (-1.1 ; -0.6) -1.3* (-1.4 ; -1.1) C00-C97
**C17, C23, C24, C26-C32, C37-C41, C45-C49, C51, C52,C57-C60, C62-C66, C68-C80, C97
Number of cases (n); Mortality rate standardized by age (ASR).
APC: Annual Percent Change. APC is calculated for the period 1984-2015.
* The APC is significantly different from zero (p <0.05).

3. Changes in cancer morbidity and mortality
Tables 1 and  2 show the APC that represents the average percentage
of annual increase or decrease in cancer incidence and mortality rates
during the periods 1962-2012 and 1984-2015, respectively. In describing
the change, three well-defined patterns were detected: increased or
decreased when the APC was significantly different from zero (two-
tailed values ​​p <0.05); otherwise the term stable or flat was used.
The incidence rates for all cancer body sites increased in male an
annual average of 0.6% (95% CI: 0.4 - 0.8) and remained stable in
females. In contrast, mortality for all cancer body sites has been
significantly decreasing at an annual average of 0.9% in male; (95%
CI: -1.1; -0.6); and 1.3% in females, (95% CI: -1.4, -1.1).
Trend in cancer incidence rates (1962-2012)
The incidence of cancer decreased in both males and females in
the following sites: oral cavity and pharynx, esophagus, stomach,
larynx, urinary bladder and leukemia of unspecified type. The
decrease was only observed in male with pancreatic cancer and
with Hodgkin’s disease; and in females with cervical cancer.
In contrast, increased incidence rates of colorectal cancer,
melanoma, non-Hodgkin’s lymphoma and lymphoid leukemia
were found in both males and females; breast and thyroid cancer
increased in females only; and liver, prostate and testicular cancer
in males only.
In females, there was no change in the risk of morbidity due
to cancer of the liver, pancreas, lung, uterine body, ovary and
Hodgkin’s lymphoma and in males the incidence of thyroid cancer
and myeloid leukemia remained stable.
Trend in cancer mortality rates (1984-2015)
Mortality from cancer shows a favorable trend. There was only an
increase in mortality rate from melanoma and colorectal cancer
in men. In the rest of the neoplasms, there was evidence of a
decrease in mortality rates for ten of the 17 main body locations.
The decrease was observed in both males and females with cancer
of the esophagus, stomach, lung, urinary bladder, lymphomas and
multiple myeloma; only in males with cancer of the oral cavity and
pharynx; and only in females with cancer of liver, pancreas, cervix
and uterine body.
There were no changes in leukemia mortality in the entire
population of Cali. Mortality rates for liver, pancreas, and prostate
cancer remained stable in males; and females, there were no
changes in mortality rates for breast, colorectal, ovarian and
melanoma cancer.
4. Five-year net survival
For the analysis, a total of 38,671 patients diagnosed with cancer
were included through 1995-2009. The distribution of the most
frequent malignancies corresponded to breast (17.7%), prostate
(17.3%), stomach (13.1%) and colorectal cancer (9.4%), while a
smaller number of records were reported for liver cancer (2.2%),
melanoma (1.8%), multiple myeloma (1.5%) and Hodgkin’s
lymphoma (1.0%). The median age at diagnosis for the period
considered was 64 years. There has been an increase in the
number of patients diagnosed for the last study period 2005-2009.
The trend of net survival for certain types of cancer by sex and
diagnosis period 1995-2009 is shown in Figure 1.

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Figure 2  shows the 5-year net survival standardized by age for
three quinquennial periods: 1995-1999, 2000-2004 and 2005-
2009. When compared with previous periods, patients diagnosed
with cancer in the most recent period (2005-2009) marked
improvements in net survival of 5 years were observed for most
cancer sites. The proportions of increased cancer survival in
females could be explained in part by common types of cancer
in females (e.g. thyroid, breast, and cervical cancers) that have a
relatively good prognosis. When examined by year of diagnosis
and localization of cancer, in general terms it was evident that in
the last period which includes the years 2005-2009 there was an
increase in survival for most of the cancer locations except for
stomach cancer and colorectal cancer.
In the case of liver cancer, age standardization was not carried
out, because some of the age-specific 5-year net survival estimates
necessary to carry out standardization were not available (very low
survival, first year of follow-up, about 90% of patients with liver
cancer died).
On the other hand, the highest estimates of net survival for the
period 2005-2009 were seen for thyroid cancer (89.3%), prostate
(83.2%), breast (74.4%) and melanoma (65.8%). In the case of
hematolymphoid neoplasms, survival was better in patients with
Hodgkin lymphoma (64.4%) than in non-Hodgkin lymphoma
(43.3%). In leukemia and multiple myeloma survival was lower, with
estimates for the 2005-2009 period of 28.1% and 22.8% respectively.
Childhood cancer
VIGICANCER registered 1,428 children (<15 years of age) and
adolescents (15 to 18.9 years of age) between 2010 and 2016.
Ninety-six percent (n: 1,379) contributed to the follow-up (673
hemato-lymphoid tumors y 706 solid tumors). Children 5-year
overall survival (OS) was 52.0% (95% CI: 48.7, 55.3) and 44.0%
(95% CI: 35.4, 52.2) in adolescents.
Table 3  shows OS by the International Childhood Cancer
Classification 3rd version21  cancer group. Group I was the most
frequent both in children (39.7%) and adolescents (30.3%).
Within this group 79.1% were acute lymphoblastic leukemia
(ALL). Among group II, 38.4% were Hodgkin disease, 38.3% non-
Hodgkin lymphoma (without Burkitt) and 23.3% Burkitt. From
all groups, 17.2% were central nervous system tumors (group III);
being the most frequent (26.5%) in the <1 year of age group.
Infancy and early childhood malignant solid tumors frequency
was 2.3% for neuroblastoma (and other group IV tumors), 4.2%
for retinoblastoma (group V), 3.9% for Wilms tumor (and other
groups VI tumors), and 1.3% hepatoblastoma (group VII).
Malignant bone tumors (group VIII) were more frequent
in adolescents (14.9%) than in children (5.6%), with 58.9%
osteosarcomas and 32.7% Ewing sarcoma. Group IX (soft tissue
sarcomas) was similar in children and adolescents (5.0% vs. 5.9%).
Germ cell tumors (group X) showed an overall frequency of 5.2%;

1995-1999 2000-2004 2005-2009

Thyroids 68.9 (56.7 ; 81.2) 67.8 (56.6 ; 79) 90.8 (81.3 ; 98.4)

Prostate 68.1 (64.1 ; 72.1) 81.1 (78.3 ; 84) 83.2 (80.7 ; 85.8)

Hodgkin´s Lymphoma 60.7 (48.2 ; 73.2) 66.3 (55.5 ; 77.1) 61.9 (50.6 ; 73.2)

Melanoma 48.8 (34.3 ; 63.3) 55.7 (44.7 ; 66.7) 61.9 (51.0 ; 72.8)

Non-Hodgkin´s Lymphoma 22.8 (16.6 ; 29.1) 34.4 (27.5 ; 41.2) 40.3 (33.2 ; 47.4)

Colorectal 29.5 (23.2 ; 35.8) 40.7 (35.2 ; 46.2) 39.2 (34.0 ; 44.3)

Multiple myeloma 18.8 (9.4 ; 28.1) 23.0 (11.3 ; 34.7) 23.8 (15.9 ; 31.6)

Leukaemia* 11.1 (5.9 ; 16.4) 20.9 (13.6 ; 28.2) 20.5 (14.2 ; 26.7)

Stomach 16.8 (13.6 ; 20.1) 17.6 (14.4 ; 20.8) 16.8 (13.8 ; 19.7)

Lung 7.7 (5.1 ; 10.3) 7.4 (4.9 ; 9.9) 8.8 (6.3 ; 11.3)

0 10 20 30 40 50 60 70 80 90 100
Five-year net survival (%)
Figure 1a. Cali, Colombia. Cali, Net standardized survival in male by age at 5 years for the most frequent locations by period of interest and sex, between 1995 and 2009.

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1995-1999 2000-2004 2005-2009

Thyroids 70.0 (62.9 ; 77.1) 88.7 (83.6 ; 93.7) 88.4 (84.3; 92.5)

Breast 65.7 (61.3 ; 70.1) 69.7 (66.4 ; 73.1) 74.4 (71.1; 77.6)

48.9 (36.0 ; 61.8) 66.7 (58.8 ; 74.7) 68.8 (59.6; 77.9)

Melanoma

Hodgkin´s Lymphoma 52.0 (36.3 ; 67.7) 64.3 (51.9 ; 76.7) 61.8 (48.6; 75.0)

Ovary 26.0 (19.8 ; 32.2) 32.3 (27.0 ; 37.7) 34.3 (29.1; 39.5)

Non-Hodgkin´s Lymphoma 23.2 (18.1 ; 28.4) 43.4 (37.2 ; 49.7) 46.2 (40.4; 51.9)

Colorectal 27.5 (22.7 ; 32.4) 43.4 (38.5 ; 48.3) 42.2 (37.8; 46.7)

Leukaemia* 17.0 (10.0 ; 24.1) 24.4 (17.2 ; 31.5) 34.5 (28.1; 41.0)

Cervix 50.5 (46.5 ; 54.5) 56.9 (53.2 ; 60.7) 57.7 (54.0; 61.5)

26.4 (16.4 ; 36.4) 17.5 (9.0 ; 25.9) 18.3 (10.5; 26.0)

Multiple myeloma
14.0 (10.7 ; 17.3) 18.2 (14.6 ; 21.7) 18.3 (15.0; 21.5)
Stomach
5.5 (3.0 ; 8.1) 11.2 (7.7 ; 14.7) 11.1 (7.8; 14.3)
Lung

0 10 20 30 40 50 60 70 80 90 100
Five-year net survival (%)
Figure 1b. Cali, Colombia. Cali, Net standardized survival in female by age at 5 years for the most frequent locations by period of interest and sex, between 1995 and 2009.

1995-1999 2000-2004 2005-2009

Thyroids 69.6 (63.2 ; 75.9) 86.3 (81.4 ; 91.1) 89.3 (85.4 ; 93.2)

Prostate 68.1 (64.1 ; 72.1) 81.1 (78.3 ; 84.0) 83.2 (80.7 ; 85.8)

Breast 65.7 (61.3 ; 70.1) 69.7 (66.4 ; 73.1) 74.4 (71.1 ; 77.6)

Melanoma 49.1 (38.7 ; 59.6) 62.3 (55.7 ; 68.8) 65.8 (58.8 ; 72.8)

Hodgkin´s Lymphoma 54.4 (44.5 ; 64.3) 65.5 (57.2 ; 73.8) 64.4 (56.2 ; 72.7)

Cervix 50.5 (46.5 ; 54.5) 56.9 (53.2 ; 60.7) 57.7 (54.0 ; 61.5)

Colorectal 28.9 (25.0 ; 32.9) 42.3 (38.6 ; 45.9) 40.6 (37.2 ; 43.9)

22.3 (18.4 ; 26.3) 39.1 (34.4 ; 43.8) 43.3 (38.8 ; 47.9)

Non-Hodgkin’s Lymphoma
26.0 (19.8 ; 32.2) 32.3 (27.0 ; 37.7) 34.3 (29.1 ; 39.5)
Ovary
12.3 (8.1 ; 16.5) 22.3 (17.1 ; 27.5) 28.1 (23.2 ; 32.9)
Leukaemia*

Multiple myeloma 20.6 (13.8 ; 27.3) 21.0 (13.6 ; 28.3) 22.8 (16.9 ; 28.8)

Stomach 15.7 (13.3 ; 18.1) 17.9 (15.5 ; 20.3) 17.4 (15.2 ; 19.6)

Lung 6.6 (4.7 ; 8.6) 9.0 (6.8 ; 11.1) 9.6 (7.6 ; 11.7)

Liver 4.1 (0.3 ; 8.0) 3.8 (0.7 ; 6.8) 5.0 (1.9 ; 8.0)

0 10 20 30 40 50 60 70 80 90 100
Five-year net survival (%)
Figure 2. Cali, Colombia. Five-year net survival standardized by age after diagnosis by period of interest, both sexes between 1995 and 2009.

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Table 3. Cali, Colombia, 2010-2015. Frequency of children and adolescent cancer cases and 5-year overall survival by ICCC-3 groups 21
Group ICCC-3 Children % Adolescents % OS 95% CI
I 453 39.7 87 30.3 48.3 43.3 53.2
II 112 9.8 34 11.9 74.1 65.5 81.0
III 209 18.3 36 12.6 40.2 32.4 47.7
IV 32 2.8 1 0.3 39.2 21.5 56.6
V 60 5.3 0 0.0 74.8 61.1 84.2
VI 56 4.9 0 0.0 62.5 47.3 74.5
VII 19 1.7 0 0.0 47.8 9.6 79.3
VIII 64 5.6 43 15.0 29.4 18.9 40.5
IX 57 5.0 17 5.9 32.3 19.9 45.3
X 39 3.4 27 9.4 61.2 45.2 73.8
XI 27 2.4 37 12.9 76.2 59.8 86.6
XII 13 1.1 5 1.7 56.3 20.9 80.9
Total 1,141 100.0 287 100.0 50.8 47.7 53.8
ICCC-3: International Classification of Childhood Cancer version 3
OS: 5-year overall survival. 95% CI: 95% Confidence interval

in children 3.4% and in adolescents 9.4%. Epithelial malignant for the last 55 years, which allows detailed analyses of the 50
tumors (group XI) had higher frequency in adolescents (12.9%) year-incidence (1962-2012), 30 year-mortality (1984-2015) and
than in children (2.4%). In this group, thyroid tumor was the most 15-year-survival (1995-2009) of cancer in the region.
frequent 51.5%. Non-specified cancers (group XII) were 1.3%.
Cali has experienced profound epidemiological and demographic
Discussion changes in the last half of the century. The population has
quadrupled and has aged, and the life expectancy at birth increased
The RPCC of Universidad del Valle provides unique information from 56.7 to 68.4 years13,15; Currently there are 33 persons 65 years
of the statistics of cancer in Cali, during the 2008-2015 period. old or over per 100 persons under 15 (Ageing index)13.
This information is necessary for health authorities to make
estimates of cancer risk for other regions of Colombia that are The offer of oncology care services in Cali corresponds to one
lacking cancer registries. These statistics complement previous sixth of the country’s installed capacity16 and attends around 9,000
reports5,22  and provides uninterrupted continuous monitoring new cases of cancer per year, half are permanent residents and the
Infection-related Cancer Screening-related Cancer Tobacco-related Cancer
Age-standardized rate (World population) x 100,000 person-year

A
80 80 80
60 60 60
40 40 40

20 20 20

10 10 10

5 5 5

1 1 1
1965 1975 1985 1995 2005 2015 1965 1975 1985 1995 2005 2015 1965 1975 1985 1995 2005 2015

Stomach Prostate Lung

Cervix Uteri Breast Oral Cavity
Colorectal Pancreas

B
80 80 80
60 60 60
40 40 40

20 20 20

10 10 10

5 5 5

1 1 1
1965 1975 1985 1995 2005 2015 1965 1975 1985 1995 2005 2015 1965 1975 1985 1995 2005 2015

Stomach Prostate Lung

Cervix Uteri Breast Oral Cavity
Colorectal Pancreas

Figure 3. Cali, Colombia. Trend in cancer rates

Calendar in the last 55 years
Years
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rest are patients from the south-west, a region that represents 20%
of the Colombian population13. Eighty five percent of the oncology
services in Cali are private16, the care is not comprehensive and
there are several barriers to accessing quality oncological care
services. Government measures aimed at stabilizing the health
system have been unsuccessful and there has been evidence of
discriminatory behavior and risk selection of the oncological
patients by the health care provider entities responsible for
managing the risks related to the disease23. Therefore, the clinical
outcomes remain unfavorable primarily because patients present
late with in advanced stages of the disease and, thus, survival is low
for most types of cancer compared to that observed in Europe and
the United States24,25.
Coinciding with demographic changes there are significant
variations in trends, patterns and differences in incidence rates and
cancer mortality. The increase or decrease in the risk of morbidity
and mortality due to this group of diseases is determined by
different factors. So far, some are recognized and most are still to
be identified. These changes may be the result of variations in the
exposure of the population to different risk factors, better access
to health services and improvement in diagnostic and treatment
techniques26,27.
Although several threats persist, the available information shows
evidence of advances in the control of some types of cancer in Cali.
Overall cancer mortality decreased significantly in both males
and females with an annual change rate of 1% during the period
1984-2015 ((APC: -0.9, 95% CI: -1.1; -0.6) and (APC: -1.3, 95% CI:
-1.4; -1.1)). The magnitude of the decrease was greater in patients
with cancer related to tobacco consumption, infectious agents
and hematolymphoid neoplasms where important therapeutic
advances have been made (Fig. 3).
Cancer related to infectious agents
The incidence and mortality rates for stomach and cervix uteri
cancer have decreased significantly over the last 55 years (Fig.
3). The descent is monotonic, continuous and began before
knowing the prominent role in the processes of carcinogenesis
of Helicobacter pylori28 and the Human Papilloma Virus (HPV)29.
These changes are not related to specific interventions against
these infectious agents, they are the result of progress in the
development and improvement of sanitary conditions. Economic
development determined changes in lifestyles and modifications of
the known risk factors for gastric cancer. Refrigeration facilitates
the consumption of fresh foods and limits the use of chemical-
based food preservation methods (salting, desiccation, smoking,
and acidification).
In the 21st century, gastric cancer still represents a great social
burden in Cali and Colombia because it causes the highest number
of deaths from cancer3,5,22. The disease is fatal when discovered
clinically because the diagnosis is usually made in the advanced
stages. From 1995 to 2009, the 5-year net survival of patients with
gastric cancer in Cali was less than 20%, with a healing fraction of
15% and an average survival time of 6 months for uncured cases22;
similar results were observed in Chile and Costa Rica. But in other
Latin American countries with equal or lesser development, the
survival estimates were around 30%, which are comparable to
those observed in the United States and Europe. It is also possible
30
that estimates of gastric cancer survival in Ecuador and Cuba may
be overestimated24,25.
Despite the continuous decline in the incidence and mortality of
infection-related cancers, rates remain high and the number of
cases continues to increase due to aging and population growth30.
It is very likely that this downward trend will continue, even
without additional interventions, in the years to come; however,
under natural conditions, it will likely take many decades, if not
centuries, before the incidence and mortality rates reach the
values ​​currently observed in the United States and Europe. It is
a priority to implement additional measures to accelerate the
decline, improve survival and achieve control30.
The perspectives for the control of gastric cancer are uncertain
because therapeutic advances are insufficient, the pre-clinical
results of efforts to develop vaccines against H. pylori have been
disappointing31; and the early detection of gastric cancer in
Latin America has shown unreliable results32,33  and low cost-
effectiveness34. During the first stages of tumor growth, cancer
is clinically silent. Therefore, an alternative to control, is the
implementation of primary prevention programs which would
help eradicate H. pylori infection by reducing the risk of developing
gastric cancer in people without precursor lesions30,34,35. Due to
the above, it is necessary to develop 1) monotherapies to facilitate
adherence to antibiotic treatment and 2) accurate non-invasive
tests to identify premalignant gastric lesions and thus serve as a risk
stratification tool of patients. The simultaneous detection of serum
pepsinogens and antibodies against  H. pylori  has achieved this
goal in Japan35,36. This strategy has not been adequately validated
in Latin America and continues to be an option that requires
exploration with a well-founded project of implementation.
The picture is different and more favorable for females with cervix
uteri cancer (CUC). Mortality rates in Cali are close to the PDPCC
goal4, but they are still three times higher compared to the United
States and Europe; where the risk of cervix uteri cancer is half
of that observed in Cali. The incidence and mortality rates have
declined for many reasons, including declining fertility rates,
improved socio-economic conditions and the establishment of a
citywide program to prevent cervix uteri cancer via a widespread
use of pap smear29,37.
The knowledge that certain genotypes of VPH infection are
necessary to cause cervix uteri cancer has created new strategies
for its prevention in the current PDPCC. As of 2012, the national
guidelines for vaccination against VPH are established and coverage
of 80% has been achieved, which unfortunately is now below 10%
because of a mismanaged episode of massive psychogenic reaction
in Carmen de Bolívar, a Colombian rural region. This reaction
was supposedly associated with the VPH vaccine38. To increase
the accuracy of cervix uteri screening, the Ministry of Health of
Colombia incorporated HPV testing in cervical cancer screening
programs. It is expected to achieve coverage of 80% of the target
population in 20214. These measures are essential to accelerate the
control of this disease because the 5-year net survival of females
with cervix uteri cancer in Cali was 57%, 10% points below that
observed in affluent countries24,25.
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Cancer related opportunity screening activities
Prostate and breast cancer are the leading cause of cancer-related
morbidity in males and females in Cali, respectively5. In Colombia
there are no organized screening programs for either cancer
and cancer control is based on specific opportunistic screening
activities. Mammography, digital rectal examination and PSA
allowed us to detect cases of disease that were previously unknown
and contributed to increasing the incidence rates before the first
quinquennium of the 21st century and since then, it has begun
to decline. Most, but not all, of the increase may be due to earlier
detection of the disease. Once the use of screening tests had been
established the rates tended to stabilize as long as other factors
causing the disease had not changed.
These changes were more evident in the population subject to
screening, the group of 50-69 years of age, where there was also
a turning point in the trend of incidence. Similar changes were
documented in Costa Rica and Ecuador at the end of the first
decade of the 21st century and were observed in Europe and the
United States 20 years earlier.
Mortality from prostate cancer has decreased consistently since
1984 with an average annual percentage decrease of 2%; the decline
occurred earlier than expected. This could not be attributed
exclusively to the screening activities (Fig. 3). An influential and
perhaps determining factor is the evolution of treatments with
curative intent; it is likely that the use of PSA and digital rectal
examination have contributed to maintaining and consolidating
this trend39. However, mortality from breast cancer remained
stable during the study period (Fig. 3).
The United States and Europe have made great advances in the
control of prostate and breast cancer. Despite the high incidence
rates (ASR: 119.8 and ASR: 124.9, respectively); the 5-year net
survival is around 98.9% and 89.7%; and mortality rates around
(ASR: 20.1, ASR: 21.2), respectively11,24. In Cali, 5-year net survival
for the same neoplasms was 83.2% and 74.4%; and the mortality
rates around (ASR: 17.4 and ASR: 13.8), respectively. The
existence of a gap of 15 percentage points in 5-year net survival in
a population where incidence rates are half of those observed in
affluent countries40, suggests that the diagnosis of cases is made at
more advanced stages and / or that the tumors are more aggressive.
This will remain an area of future investigation.
The incidence and mortality due to colorectal cancer continues
to rise in males and females in Cali. The reasons are that the
screening activities are incipient, and the risk factors are difficult
to control or are not clearly identified41; it is a priority to promote
an organized screening program to reverse the current trend.
Until this intervention occurs, oncological care services must be
oriented to the early diagnosis of suspected cases.
Cancer related to tobacco use
The trend in the incidence of lung cancer correlates with the historical
patterns of prevalence of cigarette smoking and there is sufficient
evidence of a causal relationship between cigarette smoking and
various types of cancer. The reduction in the number of cancer cases
related to tobacco use in Cali, has been interpreted as a successful
example of cancer control. This was due to the implementation of
a very strong anti-smoking government campaign implemented in
the seventies and that has been consolidated in
31
the 21st century. The incidence rates of lung cancer for both sexes
in Cali reflect the end of a tobacco-related epidemic that began in
the 1970s and was interrupted around the 1980s5,42,43. Since then,
there has been a significant decrease in tobacco-related cancer
incidence and mortality: oral cavity and pharynx, esophagus,
pancreas, lung and urinary bladder. The decrease was more
consistent in the oral cavity and lung cancer in both males and
females.
Net survival estimates
Surveillance of cancer survival is important for health
organizations, civil society and research agencies because it serves
to formulate strategies and prioritize cancer control measures, and
to evaluate effectiveness, as well as the cost effectiveness of these
strategies 1.
At the beginning of the 21st century, we began to monitor trends
in cancer survival in Cali. The relative survival (without age-
adjustment) was estimated for 16,064 patients diagnosed with
prostate, breast, colorectal, cervical, stomach and lung cancer
through 1995-200422. The present study, covers 38,671 patients
diagnosed with invasive primary cancer in 14 body locations
representing around 71.8% of the global cancer burden in Cali
(15-year period 1995-2009). Furthermore, the accuracy of the
previous estimates was improved through the implementation of
the new unbiased Pohar-Perme estimator44-46.
Coinciding with the implementation of the new health system in
the 1990s, survival improved for most of the neoplasms in the first
five-year period of the 21st century compared to the 1995-1999
period. This trend stagnated in the five-year period 2005-2009.
The 5-year net survival was like that found in Argentina, Chile,
Ecuador and Costa Rica and very low compared to that observed
in developed countries24.
Certification of cancer mortality
Information on cancer mortality in liver, lung, brain and bones
should be interpreted with caution, because in these sites, the
occurrence of metastasis is frequent. In the Cali cancer registry,
we found evidence that the primary site of some of these cancers
came from locations different than these organs. It is important
to understand that 45% of liver cancer cases corresponded to
metastasis. It was also established that cancers of the bone (46%),
lung (15%) and CNS (10%) corresponded to metastasis. There
were 2,447 new cases and 450 deaths from cancer. The coding of
the body locations made by the vital statistics office and the cancer
registry were compared. The concordance (Landis criteria47 for the
coding of cases of liver, bone and lung cancer were considerable
(Kappa = 0.64, 0.67 and 0.79, respectively) and the highest was for
malignant tumors of the CNS (Kappa = 0.90).
Childhood cancer
About 200,000 new childhood cancer cases per year are diagnosed
in the world48, 84% occurring in low and middle-income
countries49,50. Taken into account that cancer in children is not
amenable to primary or secondary prevention, survival is the most
relevant metric to evaluate efforts aimed to control cancer burden
in this population group. Cali’s 5-year OS (51%) is 26% to 32%
lower to outcomes reported in more affluent countries (77% to
83%)51,52. This implies that if in Colombia 1,500 to 1,600 children
are treated for cancer per year then after 5 years 765 to 816 had
 Bravo LE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
died, and 390 to 512 would be preventable deaths. This survival
gap persists in all cancer groups, except for Hodgkin disease (7%
difference; 5-year OS: 88% vs 95%). Effectiveness decrease in
cancer treatment is mainly related to intensity lost. Chemotherapy
intensity is related both to dose and time interval among doses.
Therefore, effectiveness of treatment is very dependent on the
delays in treatment administration (adherence to treatment),
being treatment abandonment the extreme example of this
principle. Intensity lost has multifactorial causes involving the
patient, their families, health providers, and the health system.
Other path to reduce survival is due to treatment mortality and
not because disease. This adverse outcome is both related to access
to supportive care and advance disease at diagnosis. Access to
timely and correct diagnosis and treatment is particularly related
to poor outcomes in tumors that are dependent of the stage at
diagnosis to achieve cure; retinoblastoma is the best example of
this. Nevertheless, in the Latin-American context, the Argentinian
hospital registries system reports a 3-year OS of 61.7%53, which
compares favorably with Cali´s 3-year OS of 56.6% for this cohort.
Limitations
RPCC does not actively monitor adults, and Cali lacks reliable
statistics on population migration13. The RPCC has information
about the cause of death through death certificates, but in some cases
it can be difficult to determine if cancer is the basic cause of death.
Strengths
The RPCC has participated in many other collaborative studies
and has been an advisor to the Colombian government in the
evaluation of PBCR in the country and its data have contributed
significantly to different aspects of cancer control in Colombia.
The collaborative work with the SSPM of Cali facilitates access
to information on general mortality and cancer; and allows an
independent source of verification of new cases of cancer. Access
to the information system of the Ministry of Health (SISPRO) and
to the assurance databases provides a permanent update of the
vital status and date of last contact.
Acknowledgements:
To all patients and to all oncology care services in Cali. This
research was funded and carried out by Universidad del Valle.
Funding:
COLCIENCIAS: 1106-40820552
COLCIENCIAS Young researchers and innovators program:
No.463-2008
COLCIENCIAS Young researchers and innovators program:
No.645-2014
National Institute of Cancerology No.941-2006
National Institute of Cancerology No.C0026-2009
National Institute of Cancerology No.0511-2011
National Institute of Cancerology No.0214-2012
National Institute of Cancerology No.0378-2014
Univalle-Vandervilt University-NIH-USA (Prime Award No.2
P01 CA028842-24, Subaward No. VUMC3239, 2009-2015)
Universidad del Valle, Bristol Myer-Squibb Laboratory (GRANT
COL 048-2008, COL 039-2009)
Conflict of interest:  1985-2020. Bogotá: Departamento Administrativo Nacional de
The authors declare no conflict of interest
32
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Original article

Trends in cancer incidence and mortality over three decades in Quito - Ecuador
Tendencias en incidencia y mortalidad por cáncer durante tres decadas en Quito - Ecuador

Fabián Corral Cordero1, Patricia Cueva Ayala2,3, José Yépez Maldonado2,3, Wilmer Tarupi Montenegro4

1
Director Honorífico de los Registros de Cáncer del Ecuador – Fundador del Registro Nacional de Tumores
2
Registro Nacional de Tumores. Quito, Ecuador
3
Sociedad de Lucha contra el Cáncer. SOLCA. Quito, Ecuador
4
Facultad de Ciencias de la Salud, Universidad Tecnológica Equinoccial, Ecuador.

Corral CF, Cueva AP, Yepez MJ, Tarupi MW. Trends in cancer incidence and mortality over three decades in Quito - Ecuador. Colomb Med (Cali). 2018; 49(1): 35-41.
Doi: 10.25100/cm.v49i1.3785.

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 01 March 2018
Revised: 14 March 2018
Accepted: 23 March 2018
Keywords:
Incidence, mortality, cancer,
Ecuador, Latin America.
Palabras clave:
Incidencia, mortalidad,
cáncer, Ecuador, América
latina
Introduction: The National Registry of Tumors has collected,
processed, analyzed and regularly disseminated information on new
cases of cancer diagnosed in the city of Quito, Ecuador over the last
three decades.
Aim: This article analyzed the trend of cancer incidence and
mortality rates for the period 1985-2013.
Methods: Incidence and mortality rates standardized by age
were estimated by the direct method, using the world standard
population. Analysis of the time trends, from selected locations, the
joinpoint regression was used.
Results: A decrease in the incidence and mortality rates of cervical
and stomach cancers were documented. There was an increase in
breast and colorectal cancer rates. The increase of the incidence
rate of thyroid cancer in women was notorious. Lung cancer also
increased in women while in men their values remained stable.
Conclusion: There are important variations in the evolution of
cancer in Quito; the information presented is an instrument for
monitoring and evaluating the interventions that are developed in
the Country.
Introducción: El Registro Nacional de Tumores ha recolectado,
procesado, analizado y divulgado regularmente la información de los
casos nuevos de cáncer diagnosticados en la ciudad de Quito, Ecuador
durante las últimas tres décadas.
Objetivo: Analizar la tendencia de las tasas de incidencia y mortalidad
por cáncer durante el periodo 1985-2013.
Métodos: Se estimaron las tasas de incidencia y mortalidad
estandarizadas por edad a través del método directo, utilizando la
población estándar mundial. Para el análisis de la tendencia de las
tasas, de localizaciones seleccionadas, se utilizó la regresión joinpoint.
Resultados: Se documentó un descenso de las tasas de incidencia y
mortalidad de los tipos de cáncer de cuello uterino y estómago. Existe
incremento de las tasas de cánceres de mama y colon-recto. Es notorio
el crecimiento de la tasa de incidencia de cáncer de tiroides en mujeres.
El cáncer de pulmón se incrementó en las mujeres en tanto que en los
varones sus valores se mantuvieron estables.
Conclusión: Se evidencian importantes variaciones en la evolución del
cáncer en Quito, la información presentada constituye un instrumento
para el seguimiento y evaluación de las intervenciones que se
desarrollen.

Corresponding author:
Directora del Registro Nacional de Tumores (RNT) – Sociedad de Lucha
contra el Cáncer. SOLCA Quito. Hospital Oncológico "Solón Espinosa
Ayala". Av. Eloy Alfaro 5394 y Los Pinos (QUITO). Phone: (593 2) 2419775.
Casilla 17-11-4965 C.C.I. Quito, Ecuador. E-mail: patycuev@hotmail.com.

35
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Introduction
The experience and consolidation of cancer population registries
had their beginning in Hamburg, Germany in 19291. Its greatest
impulse comes from the Conference of Copenhagen which took
place in 1946, and recommended the establishment of Cancer
Registries Worldwide. In 1966 the International Association of
Cancer Registries (IACR) was created as part of the International
Agency for Research on Cancer (IARC). This entity brings
together, supports and sets the guidelines for the development and
implementation of cancer registries in humans across the world.
In Latin America, the first cancer registry appeared in the 1950s2 in
Puerto Rico, and the second one in Cali, Colombia in 1962. This
encouraged the consolidation of the proposal in Ecuador. In 1984,
within the Cancer Fighting Society (SOLCA) Quito Nucleus, the
National Tumor Registry (NTR) was created3. Since its establishment
it has collected, processed, analyzed and regularly disseminated
information on new cases of cancer diagnosed in the city of Quito.
The present study analyzes the trend of incidence and mortality of
the main types of cancer in the city of Quito, from 1985 to 2013.
Materials and Methods
The NTR registers all cases of cancer diagnosed in the city of Quito
using a methodology which is adopted internationally (IACR). The
information is obtained through an active process, in which a group
of technicians goes to the pathology, hematology and cytology
laboratories of all public and private health center establishments in
Quito. They review the clinical records to detect diagnosed cancer
cases, and then read the clinical history or contact the treating doctor
to obtain more information about the patient. This methodology
guarantees that there are no duplication of cases.
The cases that never underwent microscopic examination are
captured in the National Institute of Statistics and Census (INEC)
through the review of “Hospital discharges” and in the “Deaths by
cancer” occurred in the city of Quito, which constitute approximately
6% of new cases of cancer. A limitation of hospital discharges is not
designed to adequately discriminate the multiple occasions that the
same patient enters and leaves a hospital or for cancer cases that
do not require hospitalization. Hospital discharges and deaths are
compared with the registry database, with the aim of identifying new
cases or updating the vital status of previously registered patients.
extension of the tumor. Staging is performed for the eight most
frequent locations (cervix, breast, prostate, lung, colon-rectum,
stomach, thyroid and lymphomas).
A Case is considered to be any invasive or in situ neoplasia incident
in the year, with or without histological verification which occurs
in the population of inhabitants in the city of Quito.
Tumors of an uncertain nature are not recorded. Since 2005, the
information has been collected and processed with the CIEO3
Classification. Tumors are recorded, not patients. The definition of
multiple tumors is established using the criteria defined by the IACR4.
The information collected is validated through quality controls
checked between registrars and resolution of doubts is consulted
with the doctors of the Registry and/or the occasional support
of a pathologist. At the end of each year, the validation tool is
applied: IARCcrgTools 2.05, to establish the coherence of the main
variables that should be a population register.
The NTR has a 4th version computer system adjusted to the needs of
the implemented methodology. The data is presented according to
the International Classification of Diseases ICD 10, and analyzed, by
sex, incidence and mortality rates standardized by age (using a world
standard population and direct method). Analysis data included
the following six periods: 1985-1988, 1989-1993, 1994-1998, 1999-
2003, 2004-2008 and 2009-2013, in selected locations of the body.
To study the trend of cancer incidence and mortality rates during
the 1985-2013 period, the average annual percentage change (APC)
was estimated. In describing the change, the terms ‘’ increase ‘’ or ‘’
decrease ‘’ were used when the APC was significantly different from
zero (p <0.05); otherwise, the term “stable” was used. Significance
tests were performed using the Monte Carlo permutation technique.
All analysis were performed in the Joinpoint Regression Program
version 4.5.0.1 of the Surveillance Research Program of the National
Cancer Institute of the United States.
Population
The city of Quito is the capital of Ecuador, it is the second largest
and most populated city in the country. It is located at latitude
0 (0°13’23” South), west of the Andes Mountain Range, at 2,800
meters above sea level. The extension of the city is 127 Km2 and its
population for the year 2013, according to the Census Projections
of the year 2010 was: 1,694,086 inhabitants5.

The variables that are collected are organized into three areas: The population of Ecuador in general and of Quito city in particular,
identification of the patient, description of the tumor and clinical has experienced important changes in demographic composition.

75+ 75+
70-74 70-74
65-69 65-69
60-64 60-64
55-59 55-59
50-54 50-54
45-49 45-49
40-44 40-44
35-39 35-39
30-34 30-34
25-29 25-29
20-24 20-24
15-19 15-19
10-14 10-14
5-9 5-9
0-4 0-4
14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0
Men (%) Women (%) Men (%) Women (%)

Figure 1. Quito Population structure by age and sex: 1985-2013.

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Ecuador, over the last three decades, has developed censuses in
the years 1982, 1990, 2001 and 2010. Through its data it can be
seen that the broad base of its population pyramid decreases while
the older group increases. In Quito in 1985, 54% of its population
was under 25 years of age, while in 2013 this group was reduced
to 44%. Those aged 65 and over accounted for 4.3% in 1985 and
in 2013, 6.5% (Fig. 1). The projection of population data of the
intercensal years are provided by the INEC.
The age variation and the increase in life expectancy (75 years
old for females, 70 years old for males) is closely linked to the
frequency of presentation and temporary tendency of cancer.
Results
interval, the values of the annual percentage change, and the
statistical significance are also presented.
In Figure 2 we can observe trends in the incidence and mortality
of the main body locations. In men, a significant increase in the
overall incidence rate of cancer was observed, with APC of 1.4%
(Fig. 2a). The stomach cancer incidence rate reached its highest
point in the first two periods, although it was later overtaken
by prostate cancer. Also, in women, the cancer global incidence
rate increased significantly with an APC of 1% (Fig. 2b). In the
first two periods, the most frequent cancer was the cervix, and in
the following periods, breast cancer presented the highest rate.
In the last two periods, thyroid cancer appears in second place,
surpassing cervical cancer.

Table 1 shows the cancer standardized incidence rates per 100,000 In men, the cancer that caused the most deaths until the period
inhabitants according to sex, main body locations and the six time of 1994-1998 was stomach cancer. In the last three quinquennial
periods studied. The trends of the incidence and its confidence periods, the highest mortality rate was that of prostate cancer. At
Table 1. Quito, Ecuador. Incidence. Standardized rates by age for locations selected by sex. 1985-2013.
Trend of the incidence rate
1985-1988 1989-1993 1994-1998 1999-2003 2004-2008 2009-2013
Location ♂ ♀
♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ APC 95% IC APC 95% IC
Lip, oral cavity, pharynx 2.0 1.6 1.8 1.1 2.4 1.7 1.7 1.3 1.9 2.0 2.1 1.6 0.0 (-1.2; 1.3) 0.9 (-1.4; 3.2)
Esophagus 3.4 0.6 3.0 1.2 2.4 0.6 2.0 0.8 2.4 0.6 1.4 0.7 -3.1* (-4.6; -1.5) ~
Stomach 28.5 21.7 32.7 20.0 24.5 16.9 22.2 13.2 22.9 14.9 20.3 14.5 -1.7 (-5.3; 2.1) -1.6* (-2.7; -0.5)
rectal colon 7.3 8.2 7.4 9.0 8.7 8.1 8.9 8.7 11.3 10.2 13.2 11.9 2.5* (1.7; 3.3) 1.4* (0.6; 2.2)
Pancreas 4.4 3.6 3.7 4.2 3.8 3.5 3.2 3.1 2.8 3.6 3.2 3.9 -1.3* (-2.3; -0.3) 0.2 (-1.2; 1.5)
Larynx 2.0 0.2 1.3 0.2 1.5 0.1 1.3 0.1 1.5 0.2 1.6 0.2 -0.1 (-1.9; 1.7) ~
Bronchi Lung 7.9 3.3 10.1 3.7 8.3 4.8 8.4 4.4 8.0 5.8 8.0 6.4 -0.5 (-1.3; 0.4) 2.8* (1.7; 3.9)
Cervix - 31.0 - 32.6 - 24.8 - 19.5 - 18.6 - 18.6 - - -2.6* (-3.2; -2.0)
Uterine body - 4.8 - 5.3 - 4.5 - 4.4 - 4.4 - 5.6 - - 0.3 (-0.6; 1.3)
Breast - 25.4 - 26.6 - 28.4 - 31.4 - 36.8 - 38.8 - - 1.9* (1.4; 2.3)
Ovary - 5.7 - 6.2 - 7.5 - 6.5 - 7.8 - 7.5 - - 1.2* (0.4; 2.0)
Prostate 22.7 - 23.1 - 31.7 - 43.5 - 53.5 - 62.9 - 3.8* (2.2; 5.3) - -
Testicle 2.6 - 4.0 - 3.3 - 4.2 - 5.2 - 5.7 - 3.0* (2.0; 4.1) - -
Bladder 4.3 2.0 5.9 1.4 5.0 1.3 5.3 1.5 5.1 2.0 6.1 2.2 0.8 (-0.3; 1.9) 1.4 (-0.2; 3.0)
Thyroid 3.1 6.3 2.1 7.6 2.2 8.7 2.4 10.5 3.9 19.6 6.6 35.0 3.6 (-0.6; 8.1) 8.5* (5.6; 11.5)
Lymphoma 8.9 7.2 8.8 7.5 11.4 8.4 10.5 9.1 12.6 9.9 16.1 13.1 2.2* (1.4; 3.1) 1.7 (-1.9; 5.3)
Leukemia 7.1 5.5 6.7 5.2 8.4 7.2 7.7 6.2 7.7 6.6 8.6 7.0 0.8 (-0.1; 1.8) 1.1* (0.2: 2.1)
Melanoma 2.3 3.3 3.5 3.6 2.2 3.0 2.5 3.0 3.7 3.8 4.1 3.8 1.8* (0.2; 3.4) 1.2 (-0.3; 2.7)
All - no melanoma skin 142.3 185.9 146.8 190.1 1476 1773 158.5 167.2 182.1 201.2 200.8 207.9 1.4* (0.9; 2.0) 1.0* (0.5; 1.5)
Rates x 100,000
APC: Annual percentage change. *The APC is significantly different from zero (p <0.05)
~ It is not possible to calculate

Table 2. Quito, Ecuador. Mortality Rates Standardized by age for selected locations by gender 1985 - 2013.
Trend of mortality rate
1985-1988 1989-1993 1994-1998 1999-2003 2004-2008 2009-2013
Localization ♂ ♀
♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ ♂ ♀ APC 95% IC APC 95% IC
Lip, oral cavity, pharynx 0.8 0.5 0.8 0.3 0.8 1.0 1.0 0.8 1.0 0.7 1.3 0.8 2.4* (0.1; 4.7) ~
Esophagus 2.6 0.3 2.0 0.6 1.8 0.4 1.7 0.4 1.4 0.5 1.3 0.6 -2.3* (-3.8; -0.7) ~
Stomach 16.7 13.8 18.4 11.5 16.2 11.6 15.8 10.2 15.9 10.6 15.2 10.0 -0.5* (-0.9; -0.1) -0.9* (-1.7; -0.1)
rectal colon 3.3 2.9 3.5 3.8 4.4 4.9 5.5 4.7 5.9 5.5 7.0 6.4 3.5* (2.4; 4.6) 4.2* (0.3; 8.2)
Pancreas 2.7 2.6 2.8 3.3 3.1 2.7 2.5 2.5 2.5 3.3 2.6 3.1 -0.1 (-1.3; 1.1) 0.6 (-0.6; 1.9)
Larynx 1.0 0.0 0.4 0.2 0.4 0.1 0.7 0.0 1.0 0.0 0.9 0.1 ~ ~
Bronchi Lung 5.2 2.8 7.2 2.9 6.7 3.5 7.0 3.6 6.7 4.6 6.2 4.9 0.4 (-0.6; 1.4) 2.7* (1.6; 3.7)
Cervix - 8.6 - 10.7 - 10.5 - 10.2 - 10.3 - 8.2 - - 0.1 (-5.3; 5.8)
Uterine body - 0.4 - 1.2 - 1.5 - 1.4 - 1.6 - 1.6 - - ~
Breast - 6.5 - 7.8 - 9.6 - 12.1 - 12.4 - 12.3 - - 2.7* (1.5; 4.0)
Ovary - 2.2 - 2.4 - 4.1 - 3.5 - 4.0 - 4.2 - - 2.7* (1.3; 4.0)
Prostate 9.3 - 10.8 - 12.7 - 16.3 - 18.7 - 1.9-1.9 - 3.7* (3.0; 4.4) - -
Testicle 0.6 - 0.7 - 0.6 - 8.0 - 0.9 - 0.7 - 1.1 (-1.4; 3.8) - -
Bladder 1.0 0.5 1.9 0.6 1.8 0.6 2.7 1.0 2.4 0.7 2.6 1.2 5.7* (1.0; 10.5) 2.9* (0.1; 5.7)
Thyroid 1.1 1.4 0.9 1.7 0.9 1.2 8.0 1.3 0.9 2.0 0.9 2.2 0.3 (-2.2; 2.8) 1.8 (-1.5; 5.2)
Lymphoma 2.0 1.8 3.3 2.2 5.2 3.7 5.4 4.6 6.9 5.2 7.9 5.9 5.4* (3.9; 6.9) 5.8* (2.7; 9.0)
Leukemia 3.3 2.3 3.0 2.0 4.7 4.3 5.2 3.6 5.3 4.1 5.2 3.9 2.6* (1.5; 3.8) 2.2 (-3.5; 8.1)
Melanoma 0.3 0.7 0.8 0.6 1.0 0.9 1.1 0.9 1.4 1.4 2.0 1.5 ~ 4.7* (2.0; 7.5)
All - no melanoma skin 68.4 69.0 73.0 75.1 78.9 83.6 88.1 83.1 93.7 90.3 101.2 89.4 1.7* (1.4; 2.0) 1.2* (0.8; 1.5)
Rates x 100,000
APC: Annual percentage change.. * The APC is significantly different from zero (p <0.05)
~ It is not possible to calculate

37
 Corral CF/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

A B
Stomach Colorectal Stomach Colorectal
100 100
APC= Incidence : -1.7 ( -5,3; 2,1) APC= Incidence : 2.5* (1,7; 3,3) APC= Incidence : -1.6* ( -2,7; -0,5) APC= Incidence : 1.4* (0,6; 2,2)
Mortality : -0.5 (-0,9; -0,1) Mortality : 3.5* (2,4; 4,5) Mortality : -0.9* (-1,7; -0,1) Mortality : 4.2* (0,3; 8,2)

10 10

1 1
85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13

Incidence Mortality Incidence Mortality

Lip, Oral Cavity, Pharynx Bronchi Lung Lip, Oral Cavity, Pharynx Bronchi Lung

100 10
APC= Incidence : 0.0 (-1,2; 1,3) APC= Incidence : -0.5 (-1,3; 0,4) APC= Incidence : 0.9 (-1,4; 3,2)
Mortality : 2.4* (0,1; 4,7) Mortality : 0.4 (-0,6; 1,4) Mortality : ~

10

1
APC= Incidence : 2.8* (1,7; 3,9)
Mortality : 2.7* (1,6; 3,7)
1

0.1 0,1
85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13

Incidence Mortality Incidence Mortality

Breast Cervix Uteri

Prostate Testicle 100
APC= Incidence : 1.9* (1,4; 2,3) APC= Incidence : -2.6* (-3,2; -2,0)
100 Mortality : 2.7* (1,5; 4,0) Mortality : 0.1 (-5,3; 5,8)
APC= Incidence : 3.0* (2,0; 4,1)
Mortality : 1.1 (-1,4; 3,8)

10
10
APC= Incidence : 3.8* (2,2; 5,3)
Mortality : 3.7* (3,0; 4,4)
1

0.1 1
85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13

Incidence Mortalidty Incidence Mortality

C
Thyroids Men Thyroids Women
All cancers - Men All cancers - Women
100
APC= Incidence : 3.6 (-0,6; 8,1) APC= Incidence : 8.5* (5,6; 11,5) 1000
APC= Incidence : -1.7 ( -5,3;2,1) APC= Incidence : 1.0* (0,5; 1,5)
Mortality : 0.3 (-2,2; 2,8) Mortality : 1.8 (-1,5; 5,2) Mortality : 1.2* (0,8; 1,5)
Mortality : -0.5 (-0,9;-0,1)

10 100

1 10

0.1 1
85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13
85-88 89-93 94-98 99-03 04-08 09-13 85-88 89-93 94-98 99-03 04-08 09-13
Incidence Mortality
Incidence Mortality

Calendar Year
Figura 2. Quito, Ecuador. Rates of cancer incidence. 1985–2013 (Location selected). 2a: Men. 2b. Women. 2c: thyroides and all cancer

38
 Corral CF/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
the national level, the situation was different in terms of mortality,
since stomach cancer until 2013 was the leading cause of death
among malignant tumors. In women residing in Quito, the
behavior of mortality from gastric cancer is similar to that of men
with two specificities: a) the rates had lower values and b) in the
period of 1999-2003, breast cancer surpassed that of the stomach
as the main cause of cancer deaths.
In Figure 2 we can observe trends in the incidence and mortality
of the main body locations.
Incidence rates of gastric cancer decreased in women significantly
with a APC of -1.6. In men, the overall decrease was not significant.
However, when applying joinpoint regression, an increase was
observed in the first phase and from the period 1994-1998 until
2013, the decrease was significant. (APC -2.4, 95% CI: -3.8; -1.1).
Mortality rates decreased significantly in men and women (-0.5
and -0.9, respectively).
Colon-rectal cancer had a significant upward trend in both
APC, men (2.5) and women (1.4). The values were very similar
for both genders. Mortality rates, in men and women, increased
significantly (3.5 and 4.2, respectively)
In the 29 years of analysis, the incidence and mortality rates from
lung cancer among men have remained stable. However, in women
the increase was significant with a APC of 2.8 in incidence and 2.7
in mortality. There was a sustained and large increase in both the
incidence rate and the mortality rate of prostate cancer with an
APC of 3.8 and 3.7 respectively.
Breast cancer had an incidence and mortality rates that increased
significantly (APC 1.9 and 2.7), however in the last three
quinquennial periods the mortality rates remained stable.
There was a significant downward trend in the incidence rates of
cervical cancer (APC 2.6). The mortality rates, analyzed globally,
did not show a significant decrease.
The incidence rates for thyroid cancer have large differences in
magnitude between Men and women which accentuated with the
passing of time. Initially, a ratio of 1:2 was detected and in the final
years the ratio was 1:5. The incidence rates increased in both men
and women, especially in the last two quinquenial. In the case of
women, this increase was significant (APC 8.5).
Mortality rates in both men and women remained low, with small
variations that were not significant.
The incidence and mortality rates of lymphomas were slightly
higher in men. Among men, incidence rates increased over time
significantly (APC 2.2). Mortality rates increase in both genders
(APC 5.4 men APC 5.8, women).
The incidence rate of leukemia was higher among men. It also
increased significantly among women (APC 1.1). On the other
hand, mortality had a significant tendency to rise among men
(APC 2.6).
39
Discussion
The incidence rate in certain body locations is reflected by the
demographic, social and economic change that is occurring
in Quito and Ecuadorian society. It is essential to highlight the
importance of the cancer active registry that has been kept by the
RNT over the last three decades. This has allowed identifying the
trends of both incidence and mortality of the main types of cancer
in the city of Quito6.
While breast cancer is on the increase among women in Quito,
cervical cancer on the other hand is decreasing. This behavior
indicates the important changes in the lifestyle that women
have had, especially in the urban area and in the cities of greater
economic development. The inclusion of women in the national
economy has led to an increase in the “estrogen window of risk”
due to late pregnancies, fewer pregnancies, reduced lactation
or caloric overload7. On the other hand, the improved access to
health services8, a better educational level of women in the city9,
and campaigns of prevention, are changes that should have an
impact on the decrease in the incidence of cancer of the cervix.
The same tendency occurs more slowly in other places within the
country due to sanitary, educational and life style changes.
Thyroid cancer, which is much more frequent in women, is notable
for its tendency to increase. Comparing the increase of incidence
from 10 to 35 over the last ten years places this area among one of
the highest positions in the world10.
This increase is due to papillary cancer which represents 44% of
the cases (1985-1988) and 89% between the period 2009-2013.
Whereas in men, the increase of these rates was moderate and also
given in papillary cancer (from 40% to 84% in the same periods).
One explanation for this phenomenon is over diagnosis established
through different researches in various countries throughout the
world11. Increased medical surveillance and the introduction
of new diagnostic techniques, such as neck ultrasound (since
the 1980s) and, more recently, computed tomography (CT) and
magnetic resonance imaging (MRI), have made it possible to
detect a large number of asymptomatic and non-lethal diseases
that exist in abundance in the thyroid gland of healthy people of
all ages. On the other hand, little is known about the aetiology of
thyroid cancer so far; exposure to ionizing radiation (especially
during childhood) and a history of benign thyroid disease are
the only well-established risk factors for differentiated thyroid
carcinomas (the most common forms of thyroid cancer)12-14. Based
on this data, IARC warns against the systematic detection of the
thyroid gland cancer and the study of small nodules, and suggests
careful monitoring for patients affected by low-risk tumors.
Gastric cancer decreased in incidence and mortality in both men
and women. Worldwide, Helicobacter pylori infection is recognized
as the primary cause of gastric cancer15. Several risk factors have
also been identified, such as socioeconomic level, high-salt and
low-antioxidant diet, alcohol and, tobacco consumption16-18.
However, in Ecuador there are multiple geographical, physical,
biological, social, economic and cultural variables which could be
related to the occurrence and course of the disease. The equatorial
 Corral CF/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
location, the ethnic diversity, multiculturalism, the phenotype
of miscegenation and the limited access to education and health
services are issues that must be addressed in order to better
understand the gastric cancer disease in our country. The decrease,
both in incidence and in mortality, is most probably linked to
better socioeconomic conditions, improvement of the quality
of food and its preservation19, rather than to the intervention of
health services in the early diagnosis.
The significant increase in incidence and mortality of colorectal
cancer is probably a manifestation of changes in the lifestyles
of societies. It is known worldwide that its incidence is higher
in countries in economic transition, especially those that have
adopted lifestyles typical of industrialized countries (diets with
a low intake of fruits and vegetables, greater consumption of
red or processed meat, physical inactivity, smoking and alcohol
consumption)20.
In men, the great increase in prostate cancer incidence rates is
associated with an improvement in early diagnosis, mainly due to
the use of prostate antigen. It would be expected that this very
important increase is accompanied by a decrease in the mortality
rate, however, as has been observed in other countries21, there was
no impact on the decrease in mortality.
In women, the incidence and mortality rates of lung cancer have
increased significantly. But in men, little changes were observed
in their rates. This behavior is probably due to the changes that
occurred in the smoking behavior of both sexes. The application
of the WHO Framework Convention for the Control of Tobacco
(FCTC) and its Protocol for the Elimination of Illicit Trade in
Ecuador, makes it possible to expand measures to avoid the risks
caused by tobacco and reduce consumption. In this regard, the
information provided represents a baseline for evaluating the
performance and impact of these policies adopted in 2015, the
same year that protocol was ratified in Ecuador22.
In the Ecuadorian constitution of 2008, health was established
as a guaranteed right by the State. The health services are an
intermediary determinant of health inequities23, due to this
fact a reorganisation of the public care system Network and a
Complementary Health Network24  was proposed through the
Integral Health Care Model in Families and Communities25.
The model´s objective is the strengthening of Primary Health
Care (Renewed Health, APS-R) as a basis for the organization
and functioning of the National Health System. The use of this
model is to ensure universal access to quality, equitable, free and
efficient health services by the population. SOLCA was created as
part of the complementary health network to be a private non-
profit institution, which is financed through the sale of Social
Security Services and by substantial contributions by the Ministry
of Public Health which has had a very important role in dealing
with cancer in Ecuador. In this regard, SOLCA attended 31% of
the oncological cases of the country for the period 2009-2013, the
public sector attended almost 45% and the private sector around
24%. This distribution will improve as the consolidation of the
Integral Public Network is reached.
One of the limitations, specific to the collection of information
on deaths is the fact that we can mention the percentage of deaths
due to poorly defined or ignored causes (ICD 10: R00-R99). In
40
Ecuador during the period 2000-2004 it was 13%, in 2005-2009
it was 11% and in 2010-2014 it was 9%. In the specific case of the
RNT of Quito, the histological verification in men and women
increased from 71.0% to 87.0%, in the quinquennial periods 1986-
1990 to 2006-2010.
Finally, it is worth mentioning that during these three decades
of monitoring, the RNT has provided accurate and relevant
information for the education of health professionals. It has
contributed to designing and establishing programs for the
prevention and control of cancer. In addition, it has trained
individuals in the implementation and development of other
cancer registries in the country that use the same standardized
RNT methodology. Actually, there are registries in Quito,
Guayaquil, Manabí, Cuenca, Loja and Machala. The information
of the RNT has been included in the publication of the IACR
“Cancer Incidence in Five Continents”, (Volumes VI, VII, VIII, IX,
X and XI).
Acknowledgements:
To Solón Espinosa, undisputed leader of the fight against cancer,
to Dr. Fabián Corral, founder of the RNT, to María Belén Morejón,
Mónica Galarza, Doris Chauca, Paulina Bedón and Silvia Jacho,
for their patient and tenacious work in the RNT.
Conflict of interest:
The authors declare that there is no real or potential conflict of
interest regarding the possible publication of this work
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Control del Tabaco - Protocolo para la eliminación del comercio
ilícito de productos de tabaco. Geneva: OMS; 2013
23. Organización Mundial de la Salud. A conceptual framework for
action on the social determinants of health. Geneva: World Health
Organization; 2010. 76 p.
24. Lucio R, Villacrés N, Henríquez R. Sistema de Salud de Ecuador.
Salud Pública México. 2011; 53: 177-187.
25. Ministerio de Salud Pública (MSP). Modelo de Atención Integral
de Salud – Familiar y Comunitario (MAIS-FC); 2012. Quito, Ecuador.
Colomb Med. (Cali) 49(1): 35-41
 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original Article

Trends in cancer incidence, and mortality in Pasto, Colombia. 15 years experience

Tendencia de la incidencia y mortalidad por Cáncer en Pasto, Colombia. 15 años de experiencia

María Clara Yépez1, Daniel Marcelo Jurado1 , Luisa Mercedes Bravo1, Luis Eduardo Bravo2

1
Registro Poblacional de Cáncer del Municipio de Pasto, Grupo de investigación Salud Pública, Centro de Estudios en Salud (CESUN), Universidad de Nariño, Pasto, Colombia.
2
Departamento de Patología, Universidad del Valle, Cali, Colombia.

Yepez MC, Jurado DM, Bravo LM, Bravo LE. Trends in cancer incidence, mortality and survival in Pasto, Colombia. Colomb Med (Cali). 2018; 49(1): 42-54.
doi: 10.25100/cm.v49i1.3616.

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 19 October 2017
Revised: 16 January 2018
Accepted: 22 February 2018
Keywords:
Cancer, incidence, mortality,
trends, disease prevention.
Palabras clave:
Cáncer, incidencia,
mortalidad, tendencias,
Prevención de
Enfermedades.
Introduction: In Colombia it is necessary to continue producing
quality and continuously updated information, on the magnitude
of cancer, from cancer population registered data to contribute
to decision making, and implementation of strategies for health
promotion, prevention and treatment of cancer, in order to reduce
the impact on the population.
Objective: To describe the incidence, mortality and cancer trends in
Pasto-Colombia from 1998 to 2012.
Methods: Observational descriptive study of morbi - mortality
due to malignant tumors in Pasto. The collection, processing
and systematization of the data, was carried out according to
international standards for cancer population registries. The
incidence and mortality rates were calculated by period, sex, age and
tumor location.
Results: for the period 1998-2012 there were 8,010 new cases of
cancer, of them, 57.7% occurred in women. There were 4,214 deaths
reported, 52.0% in women. The incidence (p men= 0.7, p females=
0.3) and mortality (p men= 1.0, p females= 0.0) did not present
significant changes over 15 years of observation and the tumors that
cause greater morbi-mortality affect the stomach, cervix, breast and
prostate.
Conclusions: Cancer in general continues to be a serious health
problem for the population of Pasto.
The global behavior of cancer incidence and mortality, identify
the need to promote and strengthen promotion and prevention
programs, especially focused on tumors of the stomach, prostate,
breast and cervix that produce greater morbidity and mortality in
the population
Introducción: En Colombia es necesario que se continúe produciendo
información de calidad y actualizada sobre la magnitud del cáncer a
partir de datos de los registros poblacionales de cáncer para contribuir
a la toma de decisiones e implementación de estrategias de promoción
de la salud, prevención y tratamiento del cáncer con el objetivo de
disminuir el impacto en la población.
Objetivo: Describir la incidencia, mortalidad y tendencia del cáncer en
Pasto-Colombia durante 1998-2012.
Métodos: Estudio observacional descriptivo de la morbi-mortalidad
por tumores malignos en Pasto. La recolección, procesamiento y
sistematización de los datos se realizó de acuerdo a parámetros
estandarizados internacionalmente para registros poblacionales de
cáncer. Las tasas de incidencia y mortalidad se calcularon por periodo,
sexo, edad y localización del tumor.
Resultados: En el período 1998-2012 se registraron 8,010 casos nuevos
de cáncer, de ellos, 57.7% se presentaron en mujeres. Se reportaron
4,214 muertes, 52.0% en mujeres. La incidencia (p hombres= 0.7;
p mujeres= 0.3) y mortalidad (p hombres= 1.0; p mujeres= 0.0) no
presentó cambios significativos durante 15 años de observación y los
tumores que causan mayor morbi-mortalidad afectan al estómago,
cuello uterino, mama y próstata.
Conclusiones: El cáncer en general continúa siendo un importante
problema de salud para la población de Pasto. El comportamiento
global de la incidencia y la mortalidad por cáncer, evidencian la
necesidad de fomentar y fortalecer programas de promoción y
prevención, enfocados especialmente hacia los tumores de estómago,
próstata, mama y cuello uterino que producen mayor morbi-
mortalidad en la población.

Corresponding author:
María Clara Yépez Chamorro. Directora Registro Poblacional de Cáncer
del Municipio de Pasto. Universidad de Nariño, Ciudad Universitaria
Torobajo - Clle 18 Cr 50, Bloque Tecnológico CESUN, San Juan de Pasto –
Colombia, Tel y fax: 7312283, e-mail: cesun@udenar.edu.co.

42
 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Introduction  malignant tumours in certain populations that correspond to

8.9% of the national population (Cali, Bucaramanga, Manizales,
In recent decades, cancer has become one of the leading Barranquilla and Pasto)6,7. For this period, Colombia estimated a
causes of mortality worldwide. According to the World Health total of 62,812 new cases of cancer per year, 29,734 cases in males
Organization (WHO), this disease represents 21% of total deaths and 33,084 cases in females were estimated for the country. In
due to non-communicable diseases, and it is the second cause of males, the highest incidence of tumours occurred in: prostate,
death after cardiovascular diseases (48%)1. Different agencies both stomach, colon and rectum. In females affect the: breast, cervix,
governmental and non-governmental organizations, have stressed uteri, colon and rectum. In the same period, there were 32,653
the importance of understanding the impact of this disease, cancer deaths, 16,081 deaths in men and 16,572 deaths in females.
not only in terms of mortality but also of morbidity (incidence, The main causes of cancer mortality in men were tumours of:
prevalence and burden) and have promoted the creation and stomach, prostate and lung; in females the tumours of: breast,
strengthening of epidemiological surveillance and information cervix uteri and stomach. According to this report, for the
systems of a regional and national nature, called Population- Department of Nariño, where is located Pasto, stomach cancer in
based Cancer Registries (PBCR)2. Thus, in 1966 the International both males and females produces the highest mortality rate8.
Association of Cancer Registries (IACR) was founded, whose main
objective is to promote the monitoring of cancer in populations The Cancer Registry of Pasto, processes information on cancer
through PBCR with internationally standardized methodological cases that occur in the rural and urban area of Pasto, Colombia,
guidelines that allow the production of scientific evidence with which according to the 2005 census has a population of 382,422
quality criteria such as: comparability, comprehensiveness, validity inhabitants, 47.8% males, 52.2% females. The population is spread
and timeliness in order to base public policies and interventions out 81.7% in the urban area, and 18.3% in the rural area. Previous
for the prevention and control of cancer, as well as to evaluate its studies conducted over 1998-2007 showed that the cancer which
effectiveness3,4. produces the highest morbi-mortality in males was the stomach,
and in females the cervix uteri.
According to estimations published by GLOBOCAN, an
epidemiological surveillance system derived from PBCR, cancer In order to observe the behaviour of the different types of tumours,
is not only a problem exclusively of high-income countries(HIC), the characterization of morbi-mortality due to cancer in Pasto was
low and middle-income countries (LMIC) allow more than half carried out over the period 1998-2012, and the analysis of the
of the annual cancer burden with 7 million new cases (56%) and trend of the incidence and mortality of the main types of tumours
4.8 millions of deaths (64%), although they are the least prepared over a period of fifteen years. This study was done to contribute to
to face this situation. Without planning and control interventions decision-making and the implementation of strategies to promote
in these populations, the burden of disease due to cancer will health, prevention and treatment of cancer that help to mitigate
increase by 70%. Therefore, cancer is considered a threat to human the impact of this disease in the region9,10.
and economic development in these countries. In Latin America
and the Caribbean it is estimated that each year there are around Materials and Methods
900,000 new cases, 542,000 deaths, and more than 2 million people
Design and population
living with cancer5.
A descriptive observational study of all the malignant tumours and
In Colombia, the National Cancer Institute (NCI) estimated that cancer deaths presented on residents of The Municipality of Pasto-
for the period 2007-2011 the morbi- mortality from cancer at Colombia during 1998-2012 was conducted. The city is located in
national and departmental level from the mortality information south western Colombia and by the middle of the study period
in combination with data produced by five PBCR that followed there were approximately 350,000 inhabitants (2005), of which
the methods of the IACR and that have produced information 74.7% with health care and 57.0% living in low socioeconomic
regarding the magnitude, distribution and tendency of the neighborhoods11,12 (Fig. 1).
n n
958 Males 85-+ Females 1,059
1,195 Total people Total people 1,567
80-84
182,889 199,533
1,992 75-79 2,613
2,858 70-74 3,939
3,775 65-69 4,687
4,904 60-64 5,893
6,187 55-59 7,206
7,441 50-54 9,161
9,284 45-49 11,176
11,461 40-44 13,618
13,270 35-39 15,519
12,956 30-34 15,581
15,722 25-29 17,095
18,472 20-24 19,063
18,451 15-19 18,708
18,978 10-14 18,890
18,136 5-9 18,046
16,849 0-4 16,712
5 4 3 2 1 0 0 1 2 3 4 5
Percentage
Figur 1. Average annual person-years by sex and age group. Colombia, Pasto 2005 Resource. General
Census -2005. Colombian National Administrative Department of Statistics (DANE).
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 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Ninety per cent of the tumours that were included were
microscopically confirmed (histology, cytology, and bone marrow
aspiration); the rest, were identified using other methods valid
for the IACR (imaging, exploratory surgery, endoscopy, clinical
and death certificate) in population-based studies. The percentage
distribution of indices of data quality varies according to the
primary site of the tumour and is shown in Table 1.
For mortality analysis all deaths recorded on the death
certificate with basic cause of death C00-C99 according to
ICD-10 (International Classification of Diseases 10th edition)
were included. Deaths coded as “non-specific uterus” (C55),
corresponding to 12% of deaths due to uterine cancer, were
distributed between the category “cervix uteri” and “body of the
uterus” taking into account the proportion of deaths observed
by age, according to IACR guidelines3. 98.0% of the deaths were
certified by medical personnel, the rest were certified by non-
medical health personnel. The percentage of deaths with unknown
age was 0.3%, and the percentage of deaths with unknown primary
site (C76-C80) was 5.0%. Incident and mortality cases do not
necessarily refer to the same person.
For each person with an incident tumour and cancer death recorded
in the period, information was collected on demographic (age, sex)
and clinical conditions (date of incidence or death, primary site of
the tumour, cause of death). The date of incidence corresponds

Table 1. Indices of data quality. Males and females of Pasto, Colombia, 1998-2012
Males Females
Site ICD-10 code
n %MV %DCO %Others MI n % DCO %MV %Others MI
Oral cavity 39 84.6 7.7 7,7 0.4 45 6.7 77.8 15.6 0.3 C00-14
Oesophagus 73 86.3 12.3 1.4 1.0 36 16.7 77.8 5.6 0.9 C15
Stomach 804 80.7 12.6 6.7 0.7 495 17.2 75.2 7.7 0.8 C16
Small intestine 13 69.2 15.4 15.4 0.3 12 8.3 83.3 8.3 0.5 C17
Colon and rectum 177 84.2 6.2 9.6 0.5 242 8.7 80.6 10.7 0.6 C18-20
Anus 5 100 0.0 0.0 0.5 19 0.0 100.0 0.0 0.3 C21
Liver 82 47.6 25.6 26.8 1.4 92 38.0 37.0 25.0 1.4 C22
Gallbladder 57 45.6 14.0 40.4 0.4 154 16.2 59.1 24.7 0.6 C23-24
Pancreas 78 26.9 23.1 50.0 0.9 116 25.0 30.2 44.8 1.1 C25
Nose, sinuses etc. 7 100.0 0.0 0.0 0.7 5 20.0 60.0 20.0 1.0 C30-31
Larynx 34 85.3 8.8 5.9 0.6 2 0.0 100.0 0.0 0.0 C32
Lung 168 60.1 20.8 19.0 1.1 117 23.1 61.5 15.4 1.2 C33-34
Other thoracic organs 7 100 0.0 0.0 0.3 7 0.0 100.0 0.0 0.5 C37-38
Bone 19 94.7 5.3 0.0 0.6 21 9.5 81.0 9.5 0.9 C40-41
Melanoma of skin 56 98.2 0.0 1.8 0.2 108 0.0 99.1 0.9 0.2 C43
Other Skin 33 93.9 6.1 0.0 0.3 35 8.6 88.6 2.9 0.6 C44
Mesothelioma 6 100.0 0.0 0.0 1.0 4 0.0 100.0 0.0 0.0 C45
Kaposi sarcoma 9 100.0 0.0 0.0 0.0 1 0.0 100.0 0.0 - C46
Connective and soft tissue 66 95.5 0.0 4.5 0.3 41 0.0 97.6 2.4 0.4 C47,49
Breast 5 100 0.0 0.0 0.5 790 1.6 94.7 3.7 0.3 C50
Vulva 16 6.3 87.5 6.3 0.4 C51
Vagina 10 0.0 90.0 10.0 0.3 C52
Cervix uteri 733 4.8 91.8 3.4 0.4 C53
Corpus uteri 129 3.9 93.8 2.3 0.2 C54
Uterus unspecified 9 55.6 33.3 11.1 2.0 C55
Ovary 217 5.5 83.9 10.6 0.4 C56
Placenta 6 0.0 83.3 16.7 0.0 C58
Penis 36 91.7 2.8 5,6 0,3 C60
Prostate 626 82.3 8.3 9.4 0.3 C61
Testis 105 98.1 0.0 1.9 0.1 C62
Other male genital organs 3 100 0.0 0.0 0.0 C63
Kidney 45 71.1 8.9 20.0 0.2 41 7.3 85.4 7.3 0.2 C64
Renal Pelvis 1 100 0.0 0.0 0.0 2 0.0 100.0 0.0 0.0 C65
Bladder 92 88.0 6.5 5.4 0.3 52 5.8 82.7 11.5 0.5 C67
Other urinary organs 2 100 0.0 0.0 1.0 2 0.0 100.0 0.0 - C68
Eye 17 100 0.0 0.0 0.1 19 0.0 100.0 0.0 0.0 C69
Brain, nervous system 106 78.3 6.6 15.1 0.6 99 17.2 66.7 16.2 0.7 C70-72
Thyroid 60 91.7 5.0 3,3 0,2 302 1.7 95.7 2.6 0.1 C73
Adrenal gland 1 0.0 100 0.0 - 1 0.0 0.0 100 - C74
Other endocrine glands 1 0.0 100 0.0 - 2 0.0 100.0 0.0 0.0 C75
Lymphomas 259 96.5 1.2 2.3 0.4 210 1.0 97.1 1.9 0.4 C81-82,85,96
Multiple myeloma 39 89.7 0.0 10.3 0.6 42 4.8 83.3 11.9 0.7 C90
Leukemia 147 96.6 2.0 1,4 0,6 115 6.1 93.0 0.9 0.8 C90-95
Myelodysplastic syndromes 12 100 0.0 0.0 0.3 15 0.0 100.0 0.0 0.3 CIE-O-3: 998_/3
CIE-O3: 9950/3,
Myeloproliferative disorders 3 100 0.0 0.0 0.5 9 100 0.0 0.3
996_3/3, 9975/3
Other and unspecified 133 52.6 16.5 30.8 0.7 211 15.2 60.2 24.6 0.5 C26,39,48,76,80
All sites 3,423 80.6 9.3 10.1 0.6 4,584 8.5 83.0 8.5 0.5 C00-96
% MV: percentage of cases with microscopic verification (cytology-hematology and histology of the primary tumor)
% DCO: percentage of cases conducted on death certificate-only
% others: percentage of cases diagnosed by other methods (imaging, endoscopy and clinical)
MI: Mortality/Incidence

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 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
to the first chronological event of diagnostic confirmation of the
disease or in case of lack of data the date of death was used.
The information was collected in an active, continuous and
systematic way in all the health institutions that generate
information on cancer: hospitals, clinics, oncology units, pathology
and haematology laboratories, medical centers, specialized offices
and the Municipal Health Secretariat, responsible for processing
the death certificates. In addition, to guarantee the completeness
of the data, databases of hospital discharges, Beneficiaries Selection
System for Social Programs (SISBEN in Spanish), National Attorney
General’s Office, National Registry of Civil Status, Registry of
patients of third level hospitals , the Solidarity and Guarantee Fund -
FOSYGA and the mortality database of the National Administrative
Department of Statistics (DANE in Spanish).
The cases were entered into the CanReg5 system for the
elimination of duplicates, processing and complementation of
data. The identification of primary multiple tumours follows the
IACR standards13. For the validation of the internal consistency
between the variables, an automatic check was carried out with
the IACRcrg Tools program version 2.05 and the rare cases were
resolved in a scientific committee formed by specialists or by
consulting with the Cali Cancer Registry.
Analysis of the information
For the analysis of incidence and mortality, frequencies were
calculated such as absolute, relative, crude, specific rates (by
period, sex, age and site of the tumour or cause of death according
to the ICD-10, grouped into large categories.) and standardised by
age (ASR) to the world population standard (SEGI) by the direct
method7,14. The DANE population estimates and projections by
the middle of the period were used as a denominator at risk for
calculating the rates, which were calculated considering the basic
components of the population dynamics: fertility, mortality, and
migration (internal and international) from the population base
determined in the 2005 census, and adjusted by conciliation of the
General Census (census 1985, 1993 and 2005)15. Cases without age
(0.15%), basal cell carcinoma and squamous cell of the skin were
excluded.
The incidence and mortality results are presented in specific
Tables or Charts and the analysis of the main sites was intensified
170
160
ASR x 100,000 males or females - year
150
140
130
120
110
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Modeled rate
Females
Observed rate
Figure 2. Trend of age-standardized global rates of cancer incidence. Males and
females of Pasto, Colombia, 1998-2012. APC: Annual Percentage of change. ASR:
age-standardized Rates (SEGI world population standard) x 100,000 males or
females-year
45
because they are diseases of great relevance for the region. Crude
and standardised incidence and mortality rates are expressed per
100,000 males-year or females-year.
To assess the trend of incidence and mortality, a global analysis
between five-year periods was made and the percentage change
in rates between the last two periods was estimated. Additionally,
a trend analysis of annual incidence and mortality rates was
performed using a segmented linear regression or joinpoint,
accepting a maximum of three change points (joinpoints) with
four linear segments respectively. The annual percentage of change
(APC) was estimated in each possible segment generated between
each point and the average annual percentage change (AAPC) was
calculated for the entire period. All possible models were adjusted
with the weighted least squares method and the model selection
was made with the Montecarlo permutations test. All analyses
were carried out in the SEER stat and Joinpoint 4.0 program
produced by the Surveillance Research Program of the National
Cancer Institute of the United States16.
Ethical considerations
This study is classified as without risk research according to
resolution 8430 of 1993 of the Ministry of Health of Colombia,
since the information comes from secondary sources and has
no direct contact or intervention of the biological, physiological,
psychological or social variables of the individuals studied.
The handling of information follows the confidentiality rules
established by the International Agency for Cancer Research
(IACR) that regulate the use of data for scientific purposes without
the disclosure of personal data, guaranteeing respect and non-
maleficence towards patients. On the other hand, the Cancer
Registry of Pasto and the investigations that derive from it have
agreements with the sources of information to guarantee the
adequate flow of the data.
Results
Global incidence
During the period 1998-2012 in the municipality of Pasto, 8,010
cases of cancer were identified. (ASR 145.1 cases per 100,000
persons-year), 3,426 in males (ASR 139.1 cases per 100,000 males-
year) and 4,584 cases in females (ASR: 150.3 cases) per 100,000
females-year) (Tables 2 ​and 3).
Age-specific rate x 100,000 males or females - year
600 2,000
1,800
500
1,600
Cancer Cases (n)
1,400
400
1,200
300 1,000
800
200
600
400
100
200
0 0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +
Age of diagnosis
Cases Cases
Modeled rate Males Females
Males ASpR ASpR
Observed rate
Figure 3. Cases and specific rates by age per 100,000 males or females-year of
incidence of cancer, Pasto, Colombia, 1998-2012. ASpR: age-specific Rates x 100,000
males or females-year
 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

By sex and period, in males there were in 1998-2002, 982 cases
(ASR: 135 cases per 100,000 males-year), for 2003-2007 1,174 cases
(ASR: 147.1 cases per 100,000 males-year) and in 2008-2012 1,270
cases (ASR 136.4 cases per 100,000 males-year). In females during
1998-2002 there were 1,359 cases (ASR: 149.6 cases per 100,000
females-year), for 2003-2007: 1,541 cases (ASR: 156.1 cases per
100,000 females-year) and in 2008-2012: 1,684 cases (ASR: 147.1
cases per 100,000 females-year). The percentage of change in the
global incidence rates between the last two periods was 0.2 in males
and in females of 1.0%.
The incidence trend indicates that there were no significant
changes in the incidence rates in both males and females during
the analysed period (p-value males= 0.7, p-value females= 0.3), that
means the incidence was stable. The average annual incidence rates
standardised by age were 139.7 cases per 100,000 males-year and
150.7 cases per 100,000 females-year (Fig. 2).
Incidence by age
Cases and cancer incidence rates increase by age; 55% of incident
cases in males and 40% in females occurred after 65 years, while
2% of cases in both genders occurred in children under 15 years of
age (Fig. 3). The average age of diagnosis in males was 62.3 years
(Standard deviation SD= 18.7 years) and in females of 58.2 years
(SD= 18.1 years).
Incidence by tumour site
The most frequent tumours over the 15 years in males were
tumours of the: Stomach (23.5%), prostate (18.3%), lymphomas
(7.6%) colon and rectum (5.2%) and lung (4.9%). In females were:
breast (17.3%), cervix uteri (16.0%), stomach (10.8%), thyroid
(6.6%) and colon and rectum (5.3%). This behaviour was observed
when analysing each of the three five-year periods that comprise
the study period (Tables 2 and 3).

Table 2. Cancer incidence rates by tumour site, crude and age-standardized per 100,000 males-year. Pasto, Colombia, 1998-2002, 2003-
2007 and 2008-2012
PC(%) 2003-2007 ICD-10 code
1998-2002 2003-2007 2008-2012
Site and 2008-2012
n % CR ASR n % CR ASR n % CR ASR CR ASR
Oral cavity 15 1.5 1.8 2.3 13 1.1 1.4 1.7 11 0.9 1.1 1.1 -21.4 -35.3 C00-14
Oesophagus 35 3.6 4.1 4.6 23 2.0 2.5 3.0 15 1.2 1.5 1.5 -40.0 -50.0 C15
Stomach 296 30.1 34.8 42.6 258 22.0 28.2 32.6 250 19.7 25.3 26.7 -10.3 -18.1 C16
Small intestine 4 0.4 0.5 0.6 5 0.4 0.5 0.6 4 0.3 0.4 0.5 -20.0 -16.7 C17
Colon and rectum 42 4.3 4.9 5.9 57 4.9 6.2 7.3 78 6.1 7.9 8.4 27.4 15.1 C18-20
Anus 1 0.1 0.1 0.1 2 0.2 0.2 0.3 2 0.2 0.2 0.2 0.0 -33.3 C21
Liver 26 2.6 3.1 3.7 27 2.3 3.0 3.5 29 2.3 2.9 3 -3.3 -14.3 C22
Gallbladder 17 1.7 2.0 2.6 21 1.8 2.3 2.8 19 1.5 1.9 2.2 -17.4 -21.4 C23-24
Pancreas 18 1.8 2.1 2.6 36 3.1 3.9 4.4 24 1.9 2.4 2.8 -38.5 -36.4 C25
Nose, sinuses etc. 1 0.1 0.1 0.2 2 0.2 0.2 0.3 4 0.3 0.4 0.5 100.0 66.7 C30-31
Larynx 6 0.6 0.7 0.9 16 1.4 1.7 2.3 12 0.9 1.2 1.4 -29.4 -39.1 C32
Trachea, bronchus and lung 47 4.8 5.5 6.5 60 5.1 6.6 7.5 61 4.8 6.2 7.0 -6.1 -6.7 C33-34
Other thoracic organs 0 0.0 0.0 0.0 4 0.3 0.4 0.5 3 0.2 0.3 0.3 -25.0 -40.0 C37-38
Bone 8 0.8 0.9 0.9 6 0.5 0.7 0.8 5 0.4 0.5 0.5 -28.6 -37.5 C40-41
Melanoma of skin 11 1.1 1.3 1.4 16 1.4 1.7 2.1 29 2.3 2.9 3.1 70.6 47.6 C43
Other Skin 7 0.7 0.8 0.9 13 1.1 1.4 1.8 13 1.0 1.3 1.5 -7.1 -16.7 C44
Mesothelioma 1 0.1 0.1 0.2 2 0.2 0.2 0.2 3 0.2 0.3 0.3 50.0 50.0 C45
Kaposi sarcoma 0 0.0 0.0 0.0 1 0.1 0.1 0.1 8 0.6 0.8 0.8 700.0 700.0 C46
Connective and soft tissue 14 1.4 1.6 1.7 32 2.7 3.5 3.9 20 1.6 2.0 2.3 -42.9 -41.0 C47,49
Breast 0 0.0 0.0 0.0 2 0.2 0.2 0.2 3 0.2 0.3 0.4 50.0 100.0 C50
Penis 7 0.7 0.8 1.1 11 0.9 1.2 1.4 18 1.4 1.8 1.9 50.0 35.7 C60
Prostate 163 16.6 19.1 23.2 213 18.1 23.3 27.3 250 19.7 25.3 27.3 8.6 0.0 C61
Testis 21 2.1 2.5 2.3 43 3.7 4.7 4.3 41 3.2 4.1 3.6 -12.8 -16.3 C62
Other Male genital organs 1 0.1 0.1 0.2 1 0.1 0.1 0.1 1 0.1 0.1 0.1 0.0 0.0 C63
Kidney 15 1.5 1.8 2.1 15 1.3 1.6 1.7 15 1.2 1.5 1.8 -6.3 5.9 C64
Renal pelvis 0 0.0 0.0 0.0 0 0.0 0.0 0.0 1 0.1 0.1 0.1 C65 C65
Bladder 35 3.6 4.1 4.8 28 2.4 3.1 3.7 29 2.3 2.9 3.0 -6.5 -18.9 C67
Other urinary organs 0 0.0 0.0 0.0 1 0.1 0.1 0.1 1 0.1 0.1 0.1 0.0 0.0 C68
Eye 8 0.8 0.9 1.1 4 0.3 0.4 0.6 5 0.4 0.5 0.6 25.0 0.0 C69
Brain, nervous system 26 2.6 3.1 3.2 45 3.8 4.9 5.2 35 2.8 3.5 3.7 -28.6 -28.8 C70-72
Thyroid 12 1.2 1.4 1.5 20 1.7 2.2 2.7 28 2.2 2.8 2.6 27.3 -3.7 C73
Adrenal gland 0 0.0 0.0 0.0 1 0.1 0.1 0.1 0 0.0 0.0 0.0 -100.0 -100.0 C74
Other endocrine glands 0 0.0 0.0 0.0 1 0.1 0.1 0.1 0 0.0 0.0 0.0 -100.0 -100.0 C75
Lymphomas 72 7.3 8.5 9.0 87 7.4 9.5 10.9 100 7.9 10.1 10.6 6.3 -2.8 C81-82,85,96
Multiple myeloma 8 0.8 0.9 1.0 8 0.7 0.9 1.0 23 1.8 2.3 2.5 155.6 150.0 C90
Leukemia 40 4.1 4.7 4.5 52 4.4 5.7 6.1 55 4.3 5.6 5.9 -1.8 -3.3 C90-95
Myelodysplastic syndromes 0 0.0 0.0 0.0 3 0.3 0.3 0.4 9 0.7 0.9 0.8 200.0 100.0 CIE-O-3: 998_/3
 CIE-O3: 9950/3,
Myeloproliferative disorders 0 0.0 0.0 0.0 0 0.0 0.0 0.0 3 0.2 0.5 0.5
996_3/3, 9975/3
Other and unspecified 25 2.5 2.9 3.3 45 3.8 4.9 5.4 63 5.0 6.4 6.8 30.6 25.9 C26,39,48,76,80
All sites 982 100 115.3 135.0 1,174 100.0 128.3 147.1 1,270 100.0 128.6 136.4 0.2 -7.3 C00-96
All sites except C44 975 99.3 114.5 134.1 1,161 98.9 126.9 145.4 1,257 99.0 127.3 134.9 0.3 -7.2 C00-43,45-96
CR: Crude rate of incidence x 100,000 males-year;
ASR: Age-standardized rates (SEGI world population standard) x 100,000 males-year;
PC: Percentage of change

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Table 3. Cancer incidence rates by tumour site, crude and age-standardized per 100,000 females-year. Pasto, Colombia, 1998-2002, 2003-
2007 and 2008-2012
PC(%) 2003-2007
1998-2002 2003-2007 2008-2012 ICD-10 code
Localización and 2008-2012
n % CR ASR n % CR ASR n % CR ASR CR ASR
Oral cavity 17 1.3 1.9 1.9 21 1.4 2.1 2.1 7 0.4 0.7 0.6 -66.7 -71.4 C00-14
Oesophagus 12 0.9 1.3 1.3 13 0.8 1.3 1.2 11 0.7 1.0 1.0 -23.1 -16.7 C15
Stomach 183 13.5 20.2 20.2 175 11.4 17.6 17.1 137 8.1 12.8 11.8 -27.3 -31.0 C16
Small intestine 3 0.2 0.3 0.3 3 0.2 0.3 0.3 6 0.4 0.6 0.6 100.0 100.0 C17
Colon and rectum 63 4.6 7.0 6.8 75 4.9 7.5 7.5 104 6.2 9.7 9.0 29.3 20.0 C18-20
Anus 5 0.4 0.6 0.6 8 0.5 0.8 0.8 6 0.4 0.6 0.5 -25.0 -37.5 C21
Liver 26 1.9 2.9 2.7 32 2.1 3.2 3.0 34 2.0 3.2 2.8 0.0 -6.7 C22
Gallbladder 59 4.3 6.5 6.4 48 3.1 4.8 5.0 47 2.8 4.4 4.0 -8.3 -20.0 C23-24
Pancreas 21 1.5 2.3 2.3 54 3.5 5.4 5.5 41 2.4 3.8 3.7 -29.6 -32.7 C25
Nose, sinuses etc. 0 0.0 0.0 0.0 3 0.2 0.3 0.3 2 0.1 0.2 0.1 -33.3 -66.7 C30-31
Lung 0 0.0 0.0 0.0 1 0.1 0.1 0.1 1 0.1 0.1 0.1 0.0 0.0 C32
Trachea, bronchus and
23 1.7 2.5 2.3 37 2.4 3.7 3.8 57 3.4 5.3 4.8 43.2 26.3 C33-34
lung
Other thoracic organs 2 0.1 0.2 0.3 2 0.1 0.2 0.1 3 0.2 0.3 0.3 50.0 200.0 C37-38
Bone 5 0.4 0.6 0.6 8 0.5 0.8 0.7 8 0.5 0.7 0.7 -12.5 0.0 C40-41
Skin melanoma 31 2.3 3.4 3.3 32 2.1 3.2 3.2 45 2.7 4.2 4.0 31.3 25.0 C43
Other skin 10 0.7 1.1 1.1 10 0.6 1.0 1.1 15 0.9 1.4 1.2 40.0 9.1 C44
Mesothelioma 3 0.2 0.3 0.4 0 0.0 0.0 0.0 1 0.1 0.1 0.1 C45
Kaposi sarcoma 0 0.0 0.0 0.0 1 0.1 0.1 0.1 0 0.0 0.0 0.0 -100.0 -100.0 C46
Connective and soft
15 1.1 1.7 1.6 15 1.0 1.5 1.6 11 0.7 1 0.9 -33.3 -43.8 C47,49
tissue
Breast 219 16.1 24.2 24.4 258 16.7 25.9 27.1 313 18.6 29.3 27.7 13.1 2.2 C50
Vulva 5 0.4 0.6 0.5 5 0.3 0.5 0.6 6 0.4 0.6 0.5 20.0 -16.7 C51
Vagina 7 0.5 0.8 0.7 0 0.0 0.0 0.0 3 0.2 0.3 0.3 C52
Cervix uteri 251 18.5 27.7 27 272 17.7 27.3 27.4 210 12.5 19.6 18 -28.2 -34.3 C53
Corpus uteri 39 2.9 4.3 4.6 45 2.9 4.5 4.7 45 2.7 4.2 4.3 -6.7 -8.5 C54
Uterus unspecified 4 0.3 0.4 0.4 1 0.1 0.1 0.1 4 0.2 0.4 0.4 300.0 300.0 C55
Ovary 63 4.6 7.0 7.1 70 4.5 7.0 7.1 84 5.0 7.9 7.3 C56
Placenta 2 0.1 0.2 0.2 4 0.3 0.4 0.3 0 0.0 0.0 0.0 -100.0 -100.0 C58
Kidney 13 1.0 1.4 1.4 13 0.8 1.3 1.4 15 0.9 1.4 1.5 7.7 7.1 C64
Renal pelvis 1 0.1 0.1 0.1 0 0.0 0.0 0.0 1 0.1 0.1 0.1 C65
Bladder 18 1.3 2.0 2.0 14 0.9 1.4 1.5 20 1.2 1.9 1.7 35.7 13.3 C67
Other urinary organs 0 0.0 0.0 0.0 1 0.1 0.1 0.1 1 0.1 0.1 0.1 0.0 0.0 C68
Eye 10 0.7 1.1 1.2 7 0.5 0.7 0.7 2 0.1 0.2 0.2 -71.4 -71.4 C69
Brain, nervous system 23 1.7 2.5 2.7 27 1.8 2.7 2.8 49 2.9 4.6 4.4 70.4 57.1 C70-72
Thyroid 71 5.2 7.8 7.7 92 6.0 9.2 9.0 139 8.3 13.0 11.8 41.3 31.1 C73
Adrenal gland 1 0.1 0.1 0.2 0 0.0 0.0 0.0 0 0.0 0.0 0.0 C74
Other endocrine glands 0 0.0 0.0 0.0 0 0.0 0.0 0.0 2 0.1 0.2 0.2 C75
Lymphomas 64 4.7 7.1 6.6 71 4.6 7.1 7.3 75 4.5 7.0 6.3 -1.4 -13.7 C81-82,85,96
Multiple myeloma 7 0.5 0.8 0.8 19 1.2 1.9 2.1 16 1 1.5 1.4 C90
Leukemia 35 2.6 3.9 4.2 35 2.3 3.5 3.7 45 2.7 4.2 4.1 20.0 10.8 C90-95
Myelodysplastic
0 0.0 0.0 0.0 3 0.2 0.3 0.3 12 0.7 1.1 0.9 266.7 200.0 CIE-O-3: 998_/3
syndromes
Myeloproliferative CIE-O3: 9950/3, 996_3/3,
0 0.0 0.0 0.0 1 0.1 0.1 0.1 8 0.5 0.9 0.8 800.0 700.0
disorders 9975/3
Other and unspecified 48 3.5 5.3 5.6 65 4.2 6.5 6.4 98 5.8 9.2 8.8 41.5 37.5 C26,39,48,76,80
All sites 1359 100 149.9 149.6 1541 100 154.7 156.1 1684 100 157.7 147.1 1.9 -5.8 C00-96
All sites except C44 1349 99.3 148.8 148.5 1531 99.4 153.7 155.1 1669 99.1 156.3 145.9 1.7 -5.9 C00-43,45-96
CR: Crude rate of incidence x 100,000 males-year;
ASR: Age-standardized rates (SEGI world population standard) x 100,000 males-year;
PC: Percentage of change

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 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Stomach Cancer in Males Prostate Cancer

50 40
45 35
40

ASR x 100,000 Males - year

ASR x 100,000 Males - year

30
35
25
30
25 20
20 15
15
10
10
5 APC= -4.58*
5
APC= 1.48
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Observerd rate Modeled rate Observerd rate Modeled rate

Breast Cancer in Females Cervix Uteri Cancer

40
40
35 35

ASR x 100,000 Females - year

ASR x 100,000 Females - year

30 30
25 25
20 20
15 15

10 10
5 APC 1998-2003 = 6.08
5
APC= 1.08 APC 2003-2012 = -8.56*
0 0

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Observerd rate Modeled rate Observerd rate Modeled rate

Figure 4. Trend of age-standardized incidence rates for the most frequent tumours. Pasto, Colombia, males and females 1998-2012.
APC: Annual percentage of change. ASR: Age-standardized Rate (SEGI world population standard) x 100,000 males-year. * Statistically
significant (p <0.005)

The incidence of stomach tumours in males decreased significantly
by 4.6% (p-value= 0.0) anwnually from an ASR of 41.5 in 1998
to 19.1 cases per 100,000 males-year in 2012. In females, the
incidence of cervix uteri decreased 8.6% (p= 0.0) annually from
2003 from an ASR of 34.2 to 13.4 cases per 100,000 females-year
in 2012. The incidence of prostate tumours (p= 0.2) and breast
(p= 0.3) was constant and the average of its annual incidence rates
standardised by age was 26 cases per 100,000 males-year and 26.4
cases per 100,000 females-year, respectively (Fig. 4).
Global mortality
Over the period 1998-2012 in the municipality of Pasto there were
4,221 deaths due to cancer (ASR: 75.9 deaths per 100,000 people-
year), 1,949 in males (ASR: 78 deaths per 100,000 males-year) and
2,272 deaths in females (ASR: 74.4 deaths per 100,000 females-
year (Tables 4 ​and 5).
According to sex and period, over 1998-2002 period, 553 deaths
occurred in males (ASR: 76.9 deaths per 100,000 males-year), for
2003-2007, 648 deaths (ASR: 79.4 deaths per 100,000 males-year)
and in 2008-2012, 748 deaths (ASR: 79 per 100,000 males-year
deaths). Over 1998-2002 there were 601 deaths in females (ASR:
65.6 deaths per 100,000 females-year), for 2003-2007, 701 deaths
(ASR: 71.2 deaths per 100,000 females-year) and in 2008-2012,
970 deaths (ASR: 84.3 deaths per 100,000 females-year).
The trend in mortality indicates that there are no significant
changes in mortality rates in males (p-value males= 1.0, p-value
females= 0.0), the average annual mortality rate standardised by
age was 78.5 deaths per 100,000 males-year. While in females
mortality rates reached 2.1% per year from an ASR: of 58.6 to 86.0
deaths per 100,000 females-year, in 1998 and 2012 respectively
(Fig. 5). The average in the three quinquennial periods of the ratio
between the mortality-incidence rates (M: I) was 56 deaths per
100 diagnostic cases in males and 49 deaths per 100 diagnostic
cases in females.
Like the incidence, mortality showed the highest percentage of
cases after 65 years old, both in males (63.9%) and in females
(55.2%) (Fig. 6). The average age of death for males was estimated
at 66 years (SD= 17.8 years) and for females at 63.7 years (SD:
17.1).
Mortality by tumour site
Over 1998-2012, the main causes of cancer mortality in males
were tumours of: Stomach (28.8%), prostate (12.3%) lung (9.7%),
lymphomas and myelomas (7%) and liver (5.5%). In females
were tumours of: Stomach (16.7%), cervix uteri (12.5%), breast
(11.3%), lung (6.2%), colon and rectum (6.2%). This behaviour
was observed during the three five-year periods that comprise the
period of study (Tables 4 and 5).
Mortality caused by stomach tumours in males decreased
significantly (p-value= 0.0) 2.18% annually from an ASR of 24.5
in 1998 to 19.9 deaths per 100,000 males-year in 2012. In females,
breast cancer mortality increased (p-value= 0.0) 3% annually from

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Table 4. Cancer mortality rates by tumour site, crude and age-standardized per 100,000 males-year. Pasto, Colombia, 1998-2002, 2003-
2007 and 2008-2012.
PC(%) 2003-2007
1998-2002 2003-2007 2008-2012
Localization and 2008-2012 ICD-10 code
N % CR ASR N % CR ASR N % CR ASR CR ASR
Oral cavity 3 0.5 0.4 0.4 4 0.6 0.4 0.4 9 1.2 0.9 0.9 125.0 125.0 C00-14
Oesophagus 22 4.0 2.6 3.2 25 3.9 2.7 3.1 25 3.3 2.5 2.6 -7.4 -16.1 C15
Stomach 190 34.4 22.3 26.6 172 26.5 18.8 21.5 200 26.7 20.2 21.5 7.4 0.0 C16
Small intestine 0 0.0 0.0 0.0 2 0.3 0.2 0.2 2 0.3 0.2 0.2 0.0 0.0 C17
Colon and rectum 15 2.7 1.8 1.9 34 5.2 3.7 4.2 50 6.7 5.1 5.3 37.8 26.2 C18-20
Liver 28 5.1 3.3 4.3 48 7.4 5.2 6.4 31 4.1 3.1 3.2 -40.4 -50.0 C22
Pancreas 20 3.6 2.3 3.1 28 4.3 3.1 3.4 27 3.6 2.7 3.0 -12.9 -11.8 C25
Lung 62 11.2 7.3 9.2 61 9.4 6.7 7.3 66 8.8 6.7 7.3 0.0 0.0 C34
Skin melanoma and Other skin 9 1.6 1.1 1.3 2 0.3 0.2 0.3 11 1.5 1.1 1.1 450.0 266.7 C43-44
Breast 2 0.4 0.2 0.2 1 0.2 0.1 0.1 0 0.0 0.0 0.0 -100.0 -100.0 C50
Prostate 66 11.9 7.7 9.4 81 12.5 8.9 9.2 92 12.3 9.3 9.0 4.5 -2.2 C61
Bladder 9 1.6 1.1 1.4 7 1.1 0.8 0.7 17 2.3 1.7 1.7 112.5 142.9 C67
Lymphomas and myelomas 37 6.7 4.3 4.4 45 6.9 4.9 5.7 55 7.4 5.6 6.0 14.3 5.3 C90 ,C81-82,85,96
Leukemias 25 4.5 2.9 2.8 21 3.2 2.3 2.4 42 5.6 4.2 4.3 82.6 79.2 C90-95
Other malignant tumours 65 11.8 7.6 8.8 117 18.1 12.8 14.4 121 16.2 12.2 12.9 -4.7 -10.4
All sites 553 100.0 64.9 76.9 648 100.0 70.8 79.4 748 100.0 75.6 79.0 6.8 -0.5 C00-96
CR: Crude rate of mortality x 100,000 males-year;
ASR: Age-standardized rates (SEGI world population standard) x 100,000 males-year;

Table 5. Cancer mortality rates by tumour site, crude and age-standardized per 100,000 females-year. Pasto, Colombia, 1998-2002, 2003-
2007 and 2008-2012.
PC (%) 2003-
1998-2002 2003-2007 2008-2012 2007 and 2008- ICD-10 code
Site 2012
n % CR ASR n % CR ASR n % CR ASR CR ASR
Oral cavity 2 0.3 0.2 0.2 3 0.4 0.3 0.3 7 0.7 0.7 0.6 133.3 100.0 C00-14
Oesophagus 8 1.3 0.9 1.0 11 1.6 1.1 1.0 13 1.3 1.2 1.1 9.1 10.0 C15
Stomach 131 21.8 14.5 14.1 121 17.3 12.1 12.0 128 13.2 12.0 10.9 -0.8 -9.2 C16
Small intestine 3 0.5 0.3 0.3 3 0.4 0.3 0.3 1 0.1 0.1 0.1 -66.7 -66.7 C17
Colon and rectum 25 4.2 2.8 2.5 41 5.8 4.1 4.1 74 7.6 6.9 6.3 68.3 53.7 C18-20
Liver 31 5.2 3.4 3.6 44 6.3 4.4 4.2 46 4.7 4.3 4.1 -2.3 -2.4 C22
Pancreas 36 6.0 4.0 4.0 52 7.4 5.2 5.3 43 4.4 4.0 3.7 -23.1 -30.2 C25
Lung 38 6.3 4.2 4.0 41 5.8 4.1 4.2 62 6.4 5.8 5.5 41.5 31.0 C34
Skin melanoma and other skin 13 2.2 1.4 1.4 11 1.6 1.1 1.0 17 1.8 1.6 1.4 45.5 40.0 C43-44
Breast 69 11.5 7.6 7.6 73 10.4 7.3 7.6 115 11.9 10.8 10.4 47.9 36.8 C50
Cervix uteri 107 17.8 11.8 11.6 65 9.3 6.5 6.6 111 11.4 10.4 9.5 60.0 43.9 C53
Corpus uteri 2 0.3 0.2 0.2 14 2.0 1.4 1.5 5 0.5 0.5 0.5 -64.3 -66.7 C54
Ovary 0 0.0 0.0 0.0 30 4.3 3.0 3.2 56 5.8 5.2 5.0 73.3 56.3 C56
Bladder 7 1.2 0.8 0.8 5 0.7 0.5 0.5 14 1.4 1.3 1.3 160.0 160.0 C67
Lymphomas and myelomas 34 5.7 3.8 3.8 34 4.9 3.4 3.5 48 4.9 4.5 4.2 32.4 20.0 C90 ,C81-82,85,96
Leukemias 30 5.0 3.3 3.3 24 3.4 2.4 2.5 41 4.2 3.8 3.5 58.3 40.0 C90-95
Other malignant tumours 65 10.8 7.2 7.2 129 18.4 13.0 13.2 189 19.5 17.7 16.3 36.2 23.5
All sites 601 100.0 66.3 65.6 701 100.0 70.4 71.2 970 100.0 90.7 84.3 28.8 18.4 C00-96
CR: Crude rate of mortality x 100,000 females-year;
ASR: Age-standardized rates (SEGI world population standard) x 100,000 females-year

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 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Figure 5. Trend of age-standardized global rates of cancer mortality. Males and females of Pasto, Colombia, 1998-
2012. APC: Annual percentage of change. ASR: Age-standardized rates (SEGI world population standard) x 100,000
males-year. * Statistically significant (p <0.005)

Age-specific rate x 100,000 males of females - year

350 2,000
1,800
300
1,600
Cancer Deaths (n)

250 1,400
1,200
200
1,000
150
800

100 600
400
50
200
0 0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +

Age of death

Deaths Deaths
Hombres Mujeres
ASpR ASpR
Figure 6. Deaths and death age-specific rates due to cancer per 100,000 males or females-year of Pasto, Colombia,
1998-2012. ASpR: Age-Specific rate x 100,000 Males or females-year

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 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Stomach Cancer in Males Prostate Cancer

35 14

30 12

ASR x 100,000 Males - year

ASR x 100,000 Males - year

25 10

20 8

15 6

10 4

5 APC= -2.18* 2 APC= -0.28

0 0

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Observerd rate Modeled rate Observerd rate Modeled rate

Stomach Cancer in Females Cervix Uteri Cancer

25 16
14
ASR x 100,000 Females - year

ASR x 100,000 Females - year

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12

15 10
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10 6
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Observerd rate Modeled rate Observerd rate Modeled rate

Figure 7. Trend of age-standardized mortality rates for the most frequent tumours. Pasto, Colombia, males and females 1998-2012. APC: Annual percentage
of change. ASR: age-standardized Rate (SEGI world population standard) x 100,000 males-year. * Statistically significant (p-value <0.005).

an ASR of 6.3 in 1998 to 10.8 deaths per 100,000 females-year in
2012. Mortality from prostate tumours (p-value= 0.9), stomach
tumours in females (p-value= 0.4) and cervix uteri (p-value=
0.4) was constant and the average of their annual mortality rates
standardised by age was 9.3 deaths per 100,000 males-year, 12.3
deaths per 100,000 females-years and 9.2 deaths per 100,000
females-year, respectively (Fig. 7).
Discussion
The population characterization on cancer incidence and
mortality carried out by this study is part of the initiative to
implement programs for its control promoted by the Organization
of the United Nations, the World Health Organization (WHO),
the specialized agency in cancer IARC and at the national level
the Ministry of Health and Social Protection and the National
Institute of Cancerology of Colombia10,17. These organizations
consider that the implementation of any program to control
this disease and its outcomes should be supported by scientific
evidence and defined as: “approaches from public health, designed
to contribute to the reduction of cancer morbi-mortality, improve
the patients´quality of life with this condition through the systematic
and equitable implementation of strategies of prevention, early
diagnosis, treatment and palliation based on evidence, for the
optimal use of available resources; prioritizing in those vulnerable
populations with greater cancer burden and intervening in those
tumours that produce higher incidence and mortality”3,18-20.
At the regional level, thanks to the advances of the Cali Cancer
Registry for the systematic reporting of data on incidence, mortality
and survival to cancer, the Union for International Cancer Control
(UICC), selected the city of Cali as one of the first cities in the
world to implement the C/Can 2025 initiative: Challenge of cities
against cancer, that consists of involving all the stakeholders of
each city in the design, planning and implementation of solutions
for cancer care. The data on the characterization of cancer morbi-
mortality provided by the Cali Cancer Registry for five decades
will be the only source of evidence for evaluating the effects of the
implementation of this strategy 21. Following the model of Cali, it
is intended that the results presented in this study constitute the
baseline about the cancer situation in the municipality of Pasto to
assess the effects of the implementation of the national program for
cancer control that Colombia addressed in 20109.
In general, it is considered that the global incidence rate for the
Municipality of Pasto (ASR: 139.1 cases per 100,000 males-year
and ASR: 150.3 cases per 100,000 females-year) and in other
geographically close regions are low; Cali-Colombia (ASR: 205
cases per 100,000 males-year and ASR: 186 cases per 100,000
females-year), Manizales-Colombia (ASR: 156 cases per 100,000
males-year and ASR: 165 cases per 100,000 females-year),
Bucaramanga-Colombia (ASR: 154 cases per 100,000 males-year
and ASR: 157 cases per 100,000 females-year), Quito-Ecuador

51
 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
(ASR: 193 cases per 100,000 males-year and ASR: 199 cases per
100,000 females-year), Manabí-Ecuador (ASR: 89 cases per
100,000 males-year and ASR: 102 cases per 100,000 females-
year)24. The results observed are similar in other Latin American
countries and contrary to those reported by the majority of North
American and oceanic registers 24.
The behaviour of the global incidence rates of the populations can
be associated to lifestyles, diagnostic capacity in the health system,
but mainly to the demographic and epidemiological transition; in
populations of North America, Oceania, Europe and Asia with a
significant population aging, the risk of chronic diseases increases,
especially those of late presentation such as cancer, in contrast to
those populations with a younger population structure such as
in Latin America and Africa, which have greater public health
problems related to communicable diseases25,26.
When contrasting incidence rates with mortality rates, to establish
the mortality-incidence ratio (M:I) it can be observed that,
although the majority of North American registries have higher
rates of incidence in both males and females, the mortality and
incidence ratio reaches the lowest values (M:I: 30-40), which
means that for every 100 cases that are diagnosed there are
between 30 and 40 cancer deaths in the same period. On the other
hand, in Latin American countries the ratio M:I range between
60 and 80, its mean, for every 100 incident cases there are around
80 deaths. This is an indirect indicator of the quality of the health
system in relation to diagnostic tests for the identification of new
cancer cases and oncological treatment services to avoid deaths 7.
When comparing the incidence and mortality trends reported by
other registries that have published at least 15 years consecutively
in IC5, it is observed that the incidence of stomach tumours
decreased significantly in most populations, primarily in those
from European countries where the annual percentage of
change (APC) reported ranges between -5.1% and -3.1%, with
less decrease in North American, Oceanic and some European
countries, the APC varies between -2.9% and -2.3% and with the
lowest decrease in Latin American populations with an APC that
ranges between -2.2% and -0.9%. Only the registry of kyadondo
county-Uganda and Goiania-Brazil, have reported an increase in
the incidence of stomach cancer where the APC is 2.1% and 0.1%
respectively. In the Municipality of Pasto, the trend of incidence
and mortality from stomach cancer has achieved a significant
decrease, this behaviour is explained by the study on the trend
of incidence and mortality from stomach cancer in Cali, which
indicates that it is probably related to the decrease of the prevalent
rates of infection by Helicobacter pylori, the improvement of life
habits and early detection in the population, however, for the case
of the Municipality of Pasto, it is suggested to study in depth the
causes of this behaviour behaviour27,28.
The trend of the incidence of prostate tumours in the world has
increased significantly in most populations, in an accelerated
way in Latin American populations, some European, Asian and
oceanic with an APC that varies between 5.2% and 11.0%, has
slightly increased in some European, Asian and Oceanic countries
with an APC that fluctuates between 3.4% and 3.9%, and in Africa,
52
North America and some European countries has increased very
little, with an APC ranging between 3.3% and 1.5%. Only Indian
populations (3 records) reported that the incidence trend of
prostate cancer has decreased slightly with an APC of 0.2%. For
the Municipality of Pasto, incidence and mortality rates over time
have remained constant without showing a statistically significant
change. The analysis of this behavior should be studied to establish
the factors related to early diagnosis and treatment.
In females, the trend in the incidence of breast cancer is increasing
globally and is accentuated in populations of African and some
European and Asian registries with an APC ranging between
5.3% and 2.2%, in Latin American, oceanic and some European
populations increased moderately with an APC that varies
between 2.1% and 1.3%, and very little in North American
populations and some Asians with an APC that ranges between
0.3% and 1.2%. This behaviour is probably caused by the increase
in obesity, physical inactivity, and changes in reproductive and
other behavioural habits29. The tendency of the mortality by breast
cancer varies between regions: populations of European and
North American countries show decreasing tendencies, contrary
to the presented in the populations of South American countries.
In Pasto the incidence rate remains constant and mortality has
a tendency to increase similar to other populations of South
American countries30.
The decrease in the incidence rates of cervical cancer worldwide is
very evident, with a greater decrease in Latin American, Oceanic
and some European populations with an APC that ranges between
-2.7% and -8.6%, an average decrease in populations in North
America, some European and Asian with an APC that fluctuates
between -1.4% and -2.6% and with a reduced decrease in some
European and Asian populations with an APC that oscillates
between -0.3% and -1.1%, behaviour contrary to that reported by
African populations where the incidence trend increased with an
APC of 3.9%. In Pasto the tendency of the incidence of cervical
cancer has lowered nevertheless the tendency of the mortality
stays constant, results that reflect difficulties in the early detection
and opportune treatment.
For the Municipality of Pasto the analysis of the incidence,
mortality and behaviour of the tendency of the types of cancer of
greater occurrence becomes a base for the evaluation of the impact
of the measures of prevention, treatment, implementation of new
technologies and investigations that promote actions to control
the impact of the disease on the population.
Acknowledgment
To the Cancer Population Registry team of the Municipality of
Pasto, Population Registry of Cancer of Cali, National Institute
of Cancerology of Colombia, Municipal Health Secretariat of
Pasto-Colombia and Hospitals, clinics, clinics and laboratories for
diagnosis and treatment of cancer in Pasto.
Funding
This research was done with funding from the Center for Health
Studies of the University of Nariño, the University of Nariño
(Agreement No. 076 of 2005), The Municipal Health Secretariat
Pasto (Inter-institutional Cooperation Agreement August 25,
2005) and the National Institute of Cancerology (Convention
C0498 of 2010).
 Yepez MC/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Conflict of interest:
The authors declare to have participated in the phases of
formulation, execution, processing and analysis of the investigation
that are exposed in this article and do not have conflicts of interest
in its development and diffusion.
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 Vargas MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original Article

Cancer incidence and mortality in Barranquilla, Colombia. 2008-2012

Incidencia y mortalidad por cáncer en Barranquilla, Colombia. 2008-2012

Rusvelt Vargas Moranth1,2,3, Edgar Navarro Lechuga1,4

1
Registro Poblacional de Cáncer de Barranquilla. Barranquilla, Colombia.
2
Grupo de Investigación en Economía de la Salud, Universidad de Cartagena, Cartagena, Colombia.
3
Grupo de Investigación Sanus Viventium, Barranquilla, Colombia.
4
Grupo de Investigación Proyecto UNI. Departamento de Salud Pública, Universidad del Norte, Barranquilla, Colombia.

Vargas MR, Navarro LE. Cancer incidence and mortality in Barranquilla, Colombia. 2008-2012 Colomb Med (Cali). 2018; 49(1): 55-62.
doi: 10.25100/cm.v49i1.3627

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 30 October 2017

Revised: 07 December 2017
Accepted: 13 February 2018
Keywords:
Cancer, incidence, mortality,
population registries
Palabras clave:
Cáncer, incidencia,
mortalidad, registros
poblacionales.
Objective: To describe the behavior of cancer incidence and mortality
during 2008-2012, in the Barranquilla District.
Methods: Incident cancer cases were collected, analyzed and processed
by the Barranquilla Cancer Population Registry during the study
period. The population structure was obtained from the National
Administrative Department of Statistics (DANE) and the mortality
from the Cancer Information System in Colombia. The total and
specific crude and specific incidence rates and mortality by age and sex
were estimated, as well as by-age standardized incidence rates.
Results: Were identified 8,182 cases of cancer, excluding non-
melanoma skin (62.8% in women). 83.0% of the tumors had
histological verification and only 5.2% were DCO. The adjusted
incidence rate for all tumors was 116.5 per 100,000 in men and 155.4
per 100,000 in women. The most frequent locations were prostate
and trachea-bronchi-lung in men, while in women breast and cervix
occupied the first places. Breast and prostate had the highest mortality
rates in women and men, respectively.
Conclusion: Specific behavior of cancer incidence and mortality in
Barranquilla has important increases in main types of tumors (breast
and prostate) with respect to the country and other population
registries, provided data are key to showing a representative behavior
of the Colombian Caribbean.
Objetivo: Describir el comportamiento de la incidencia y mortalidad
del cáncer durante el período 2008-2012, en el Distrito de Barranquilla,
Colombia.
Métodos: La información fue obtenida del Registro Poblacional de
Cáncer de Barranquilla y el DANE. Se analizaron casos incidentes y
muertes por cáncer en residentes de Barranquilla, desde enero 1 de
2008 hasta diciembre 31 de 2012. Los casos informados corresponden
a tumores malignos primarios invasivos en todas las localizaciones,
excepto carcinomas de células escamosas y células basales en piel. Se
verificó la consistencia interna de los datos y se aplicaron indicadores
de calidad sugeridos por la IARC. La población en riesgo se obtuvo de
proyecciones poblacionales (1985-2020, DANE). Se estimaron tasas
específicas por sexo y edad (grupos quinquenales) y se estandarizaron
por método directo utilizando como referencia población mundial.
Resultados: Se identificaron 8,182 casos de cáncer, (62.8% en mujeres).
83.0% tuvieron verificación histológica y 5.2% fueron capturados solo
por certificado de defunción. La tasa global de incidencia de cáncer por
100,000 personas /año ajustada por edad fue 116.5 en hombres y 155.4
en mujeres. Las localizaciones más frecuentes de neoplasias malignas
fueron: próstata y pulmón en hombres, y mama y cérvix para mujeres.
Las mayores tasas de mortalidad se presentaron por los tumores de
mama en mujeres y próstata en hombres.
Conclusión: la incidencia y mortalidad por cáncer en Barranquilla
presentan aumentos importantes en los principales tumores (mama
y próstata) con respecto a otras regiones de Colombia. Los datos
aportados pueden considerarse representativos del comportamiento
epidemiológico del cáncer en el caribe colombiano.

Corresponding author:
Edgar Navarro Lechuga. Hospital Universidad del Norte, Calle 30 Autopista
Aeropuerto, Ciudadela Rotaria. E-mail: enavarro@uninorte.edu.co
55
 Vargas MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Introduction
Cancer is a public health problem. In 2012, there were near of 14
million incident cases worldwide, and the expectation is unfavorable
since this number is expected to increase to almost 24 million by
20301. Cancer is responsible for 17% of the deaths in the world,
and about a third of them are due to five potentially modifiable risk
factors: high body mass index, low intake of fruits and vegetables,
cigarette smoking, sedentary lifestyle and consumption of alcohol2,
which indicates that cancer is largely preventable.
In Colombia, cancer is the third cause of mortality3. For the 2002-
2006 period, the age-standardized incidence rate for all cancers
(with the exception of skin) was 196.9/100,000 in women and
186.6 in men4, similar to international rates, noting that close to
56% of new cases and about 70% of deaths from cancer occur in
medium and low-income countries5.
Some researchers point out that cancer mortality rates can be
taken as an indicator of health care´s quality, due to the disease’s
high probability of being prevented or treated in a timely manner6.
Therefore, it is necessary to determine the behavior, not only of
the incidence, but also of the mortality, in the different regions of
the country7, due to diversity in sociocultural, geographical and
genetic characteristics in each area4.
In Colombia, there are only five Population Base Registries
endorsed by the  Instituto Nacional de Cancerología  (National
Cancer Institute of Colombia, INC): Cali, Bucaramanga, Pasto,
Manizales and Barranquilla. Every one of the registers represents
the cultural, geographical and environmental differences of the
zones that each covers; nevertheless, the city of Barranquilla is
the only one that does not have direct environmental influences
and Andean customs, such as those of the interior of the country,
palpable in the other Registries; being a coastal city, with a tropical
climate and with characteristic that include genetic, social and
cultural elements, a product of the miscegenation marked since
the Spanish colonization and having been in previous centuries the
recipient of European and Middle Eastern migrants, it is necessary
to have a population register of cancer and analyze the behavior of
cancer in the city within the national scenario, which gave rise to
the Barranquilla Population Cancer Registry (BPCR), the result
of a strategic alliance between the INC and the  Universidad del
Norte  to consolidate incidents in the population resident in the
District of Barranquilla since January 1st, 2008, and have quality
information, which is necessary for cancer control.
The objective of present study is to describe cancer incidence and
mortality in Barranquilla for the 2008-2012 period. The BPCR
use international standards5,6  and the information consolidated
by the Sistema de Información de Cáncer en Colombia (Cancer
Information System in Colombia) to obtain valid information to
make timely and efficient decisions regarding the comprehensive
approach to cancer in the Colombian Caribbean region.
Material and Methods
Type of study
Descriptive Population base
Population at risk and area of influence
BPCR covers the urban and rural population of the District of
Barranquilla, located in the northeastern vertex of the department
(province) of  Atlántico, on the western shore of the Magdalena
River, 7.5 km from its mouth in the Atlantic Ocean. Its geographical
position is: 10º59’16” north latitude, and 74º47’20” west longitude.
The urban area is at a maximum height of 98 meters above sea
level to the west and 4 meters above sea level to the east. The city
limits to the north with the municipality of Puerto Colombia, to
the south with the municipality of Soledad, to the east with the

n n
6,601 Males 80-+ Females 11,243
6,095 Total people 75-79
Total people 9,226
9,066 290,383 70-74
327,032 12,627
12,003 65-69 14,809
17,431 60-64 20,311
23,588 55-59 26,802
29,644 50-54 34,987
35,779 45-49 40,690
35,993 40-44 41,706
36,677 35-39 40,726
43,784 30-34 47,521
50,726 25-29 54,969
53,855 20-24 52,630
53,741 15-19 51,616
53,554 10-14 51,797
53,417 5-9 51,147
52,442 0-4 50,109

10 5 0 0 5 10
Percentage
Figure 1. Population structure by age and gender. District of Barranquilla. Departamento Administrativo Nacional de Estadísticas (DANE)

56
 Vargas MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
department of Magdalena and the Caribbean Sea, and to the
west with the municipalities of Galapa, Puerto Colombia and
Tubará. The district of Barranquilla is divided into five localities
for administrative and political purposes: Riomar, Norte-Centro
Histórico, Sur Occidente, Metropolitana,  and  Sur Oriente  These
localities are subdivided into 611  manzanas (blocks)  and 188
neighborhoods, approximately. Additionally, the District includes
the corregimientos (small towns) of La Playa and Juan Mina8.
The extension of the city is 154 Km2, and the climate is dry
tropical, with an average temperature of 27.4° C. According to
DANE (Departamento Administrativo Nacional de Estadísticas-
National Administrative Department of Statistics)) projections for
the year 2010, Barranquilla had a total of 1,224,000 inhabitants,
with a density of 7,945 inhabitants per km2. The economy is
mainly based on the industrial, port and tourism sectors9. Figure
1 shows the population by gender and age for 2010.
In 2012, the District of Barranquilla had 1,352 private health service
providers (807 independent professionals and 463 IPS, which is
Healthcare-Providing Institutions or Instituciones Promotoras de
Salud) and the public network, made up of 48 health institutions, is
managed by a private operator. These institutions have more than
70 oncological services (surgical, chemotherapy, radiotherapy,
among others)10  that give Barranquilla the status of reference
center for the Atlantic Coast and the Caribbean, which is an
additional challenge for the BPCR’s aim of identifying cases from
city residents that are served by the public and private hospital
network. This has been addressed by verifying the data from 74
sources of information (pathology laboratories, imaging centers,
clinics and hospitals), each with a different recollection dynamic,
and by cross-checking the information from all databases.
The BPCR collects data on malignant tumors (and benign tumors
of the central nervous system) in all topographic locations
(in skin, only melanoma) and all age groups. The search is
active, that is, the BPCR staff periodically visits the sources of
information: histopathology laboratories, hospitals and clinics,
diagnostic centers, and institutions specialized in oncological
care in the city. Likewise, data on mortality, health insurance,
and other sociodemographic background is consulted in the
official databases of the country, such as the National Registry of
the Nation, the “Unique Registry of Affiliates” (Registro Único
de Afiliados,  RUAF) and the “Identification System of Potential
Beneficiaries of Social Programs” (Sistema de Identificación de
Potenciales Beneficiarios de Programas Sociales, SISBEN), among
others.
Barranquilla Population Cancer Registry
It initiated activities in 2008, collecting data from the 2007 cases,
which were considered as a pilot test adopting the guidelines
suggested by the IARC for population-based records. The BPCR is
made up of a multidisciplinary team of 9 people: 3 physicians (one
Master in Epidemiology, one Master in Public Health, and one
Pathology specialist), one business administrator (coordinator)
and 5 technicians (4 information collectors and 1 user) funded by
the Universidad del Norte and the INC.
Collecting and processing information
BPCR actively and passively searches for information regarding
new cases of cancer.
57
Case definition
Every malignant tumor located anywhere, including benign
neoplasms of the central nervous system that has been diagnosed
in permanent residents of the District of Barranquilla, since January
1st  of 2008, regardless of the diagnosis method, including cases
identified only by death certificate. Skin cases corresponding to
squamous and basal cell carcinomas are excluded (ICD code 10).
Primary cancer is understood as one which originates in a location
or tissue that does not correspond to the extension, recurrence or
metastasis of another primary tumor11. The most valid basis for
diagnosis is the clinical morphology (histopathological, aspiration
cytology, flow cytometry, imaging, endoscopy) and death
certificate only (DCO).
The main information sources of the registry are: pathology and
hematology laboratories, hospital discharges, imaging and early
detection centers, oncology centers, medical specialists, and
individual death certificates. To confirm if a subject is a resident
of Barranquilla, or has a high probability of being a resident, the
identification document number is used to validate residence;
this is entered on the Registraduría Nacional (National Register)
website (http://www.registraduria.gov.co/), and the subject that
appears with an assigned voting location is considered as a habitual
resident of said place; the information is then cross-checked with
the official national database of beneficiaries of social programs
(https://www.sisben.gov.co/atencion-al-ciudadano/Paginas/
consulta-del-puntaje.aspx; http://roble.barranquilla.gov.co:8888/
SisbenIII/) and healthcare (http://ruafsvr2.sispro.gov.co/; http://
www.adres.gov.co/BDUA/) which include addresses. Likewise,
through specific projects, cases are selected that are analyzed in
depth regarding sociodemographic and clinical variables.
The cases obtained from hospital discharges on one hand and
DCO on the other hand, are determined after a process of review
of clinical histories to verify their diagnosis. In the absence of
clinical information, cases are labeled as “identified only by DCO”.
Classification and codification of cases
The BPCR collects patient variables (identification number,
name, gender, and age / date of birth) and tumor variables (date
of incidence, valid basis of diagnosis, topography, morphology,
behavior and source of information). The coding is carried out
by personnel trained in the application of ICD-O-310 guidelines.
The information was initially processed in an electronic sheet
and was migrated to Canreg5 in 2016. The coding of the cases
is carried out following the Third Edition of the International
Classification of Oncological Diseases (ICD-O-3)12 and the rules
for multiple primary tumors of the International Agency for
Research on Cancer (IARC)13. For the definition of the incidence
date, the recommendations of the European Network of Cancer
Registries (ENCR)14  are considered. The database is reviewed
with IARCtools® and LinkPlus® to identify possible errors and
duplications, and to verify the internal consistency between
variables6. Cases with inconsistencies are reviewed in the sources
of information and adjustments are made.
Quality of the information
BPCR researchers, supported by the INC and the population
registries of Cali, Bucaramanga, Manizales, and Pasto, permanently
train the people participating in the RPCB in techniques and
 Vargas MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Table 1. Quality indexes by high incidence cancer location and gender. BPCR, 2008-2012
Male Female
Location
n %DCO %MV MI n %DCO %MV MI
Breast 2,094 1.0 93.0 0.2
Prostate 1,078 2.6 85.6 0.4
Cervix uteri 747 2.1 94.6 0.4
Lung 265 13.2 64.9 1.4 159 18.9 61.0 1.5
Thyroid 176 0.0 91.5 0.1
Leukaemia 156 4.5 96.2 2.4
Colon 137 10.2 73.0 0.6 175 7.4 74.3 0.7
Stomach 113 9.7 68.1 1.2
Total 3,042 6.5 80.0 0.5 5,140 3.9 85.9 0.7
DCO: only via death certificate
MV: microscopic verification.
MI: Mortality to incidence ratio

standards to collect, process and analyze information, while
being aware of the fact that the quality of the data depends on
the information obtained from the sources and of the mission
processes of the BPCR. In addition, indicators suggested by the
IARC are used to evaluate the quality of the BPCR: percentage of
cases with microscopic verification, percentage of cases registered
only by DCO, percentage of cases with unknown primary location,
proportion of cases with unknown age at the time of diagnosis,
mortality / incidence ratio, and percentage of cases with unknown
diagnosis basis. Regarding confidentiality, the BPCR adopts the
standards of the IARC, considering the purpose of collecting,
processing and analyzing the information as epidemiological15.
Estimations of incidence
Every new case registered in residents of Barranquilla between
January 1st of 2008 and December 31st of 2012 was considered. The
population at risk was calculated using the 1985-2020 projections
prepared by DANE. The specific rates were estimated by gender
and age (five-year groups) and standardized using the direct
method when using the world population (WHO) as a reference.
The relative frequencies of incident cases were estimated by
specific locations. Incidence and mortality data are presented
grouped in ICD-10 codes for comparability purposes, following
the methodology used by the IARC16.
Estimations of mortality
All deaths occurred during the same period were included with the
ICD-10 codes corresponding to malignant neoplasms, including
DCOs and deaths occurred in the observation period. It was
based on the information consolidated in the Cancer Information
System in Colombia17, which uses as population at risk the 1985-
2020 projections done by DANE. Mortality was also adjusted by
the direct method using the same reference population used in the
standardization of incidence.
Results
Global quality indicators
The percentage of histological verification for all locations was of
80.0% in men and of 85.9% in women; the five main locations by
gender showed that breast, cervix and thyroid (in women), and
leukemia (in men) had percentages higher than 90%. On the
other hand, the percentage of registrations by DCO represented
3.9% in women and 6.5% in men and had values lower ​​ than 5.0%
for prostate and leukemia (men) and breast, cervix and thyroid
(women). Regarding the Mortality-Incidence ratio, for men it had
a value of 0.5 and for women of 0.7. It is striking that, Leukemia,
Lung and Stomach in men, and Lung in women, had values higher ​​
than 1. On the other hand, there were no cases without information
in the gender and diagnostic basis variables. Table 1 shows the quality
indicators for the locations with the highest incidence by gender.
Incidence and mortality due to every cancer (all locations)
During the period of study, 8,182 new cases were registered, 62.8%
of which corresponded to women. The average age at diagnosis
was 56.1 years old for women and 61.9 for men, and 2.3% of cases
occurred in the pediatric population (younger than 15 years old).
The Age-Standardized Incidence Rate per 100,000 people-year
for all primary locations, including melanoma and excluding the
rest of skin tumors, was 116.5 in men and 155.4 in women and
the female / male incidence ratio was 1.3 (Table 2). Regarding
mortality, it was higher in men: 82.4 compared to 75.9 deaths per
100,000 people-years and the ratio of female to male mortality was
0.92 (Table 3).
Incidence and mortality by type of cancer
The five locations with the highest incidence in men were: prostate
(43.0), trachea, bronchus and lung (10.4), colon and rectum (9.6),
oral cavity (4.6) and stomach (4.4), corresponding to 61.3% of
all the types of cancer. In women, the five most recurrent types
of cancer represent 72.0% of all types of cancer, and were: breast
(65.7), cervix (26.6), colon and rectum (9.8), thyroid (5.2), and
trachea, bronchi and lung (4.8). In terms of mortality, tumors in
the lung, breast, prostate, colon and rectum and cervix represent
49.0% of all tumors, and the highest mortality rates standardized
by age per 100,000 people / year were: prostate (17.4), lung (14.3),
leukemia (6.1) and stomach and lymphomas (5.1 each) in men,
and breast (15.7), cervix (9.8), lung (7.1), colon and rectum (6.7),
and leukemia (4.4) in women. Tables 2 and ​3 show the incidence
and mortality rates according to specific locations by gender,
and  Figure 2  shows the incidence rate by age for the two main
types of cancer in women (breast and cervix) and men.
Discussion
Regarding the quality criteria, the BPCR was found to be compliant
with the requirements defined by the IARC6: microscopic
verification of at least 80% of the cases and less than 10% of the
cases registered by DCO, and the same figure for tumors with
an unknown or a poorly defined primary location. It is possible
that the M:I >1 ratio for some tumors may indicate the need to
strengthen the active search for incident cases, but it could also
indicate an excessive registration of lung, leukemia and stomach
cancer as causes of death in the DCOs.

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Tabla 2. Cancer incidence by location and gender. Barranquilla, 2008-2012

Males Females
Location n CR ASIR n CR ASIR ICD-10 Code
Oral cavity and pharynx 125 4.3 4.6 74 2.4 2.2 C00-C14
Esophagus 34 1.1 1.3 22 0.7 0.6 C15
Stomach 117 4.1 4.4 96 3.1 2.8 C16
Small intestine 10 0.3 0.3 10 0.3 0.2 C17
Colon and rectum 253 8.8 9.6 337 11.0 9.8 C18-C20
Anus 12 0.4 0.4 48 1.5 0.9 C21
Liver and bile ducts 51 1.9 2.1 56 1.9 1.8 C22
Gallbladder 19 0.7 0.8 34 1.3 1.9 C23-C24
Pancreas 41 1.1 1.2 66 1.2 1.0 C25
Nose. ear and paranasal sinus 10 0.3 0.4 9 0.2 3.2 C30-C31
Larynx 103 3.6 3.9 18 0.6 3.5 C32
Lung 268 9.4 10.4 159 5.4 4.8 C33-C34
Other thoracic organs 19 0.7 0.7 19 0.6 0.5 C37-C38
Bones and articulations 38 1.2 1.2 33 1.0 1.0 C40-C41
Melanoma of the skin 10 0.3 0.4 13 0.4 0.4 C43
Conjunctive and soft tissue 71 2.4 2.6 85 2.7 2.6 C47-C49
Breast 2,148 70.0 65.7 C50
Vulva 19 0.7 0.6 C51
Vagina 38 1.2 1.1 C52
Cervix uter 870 28.7 26.6 C53
Body of the uterus 100 3.1 2.9 C54
Ovary 143 4.7 4.4 C56
Other female organs Not Specified 8 0.3 0.3 C57
Penis 40 1.4 1.6 C60
Prostate 1,104 37.5 4.3 C61
Testícle 11 0.4 0.4 C62
Kidney 62 2.0 2.3 53 1.7 1.6 C64
Bladder 66 2.3 2.6 33 1.0 0.9 C67
Eyes and anexes 26 1.1 1.1 14 0.5 0.5 C69
Brain, CNS 107 3.7 3.9 100 3.2 3.0 C70-C72
Thyroid 31 1.0 1.1 182 5.8 5.2 C73
Other endocrine glands 10 0.3 0.3 9 0.2 0.2 C75
Hodgkin Lynphoma 35 1.1 1.1 26 0.9 0.8 C81
Non Hodgkin Lynphoma 107 3.8 4.0 9 2.6 2.4 C82-C85,C96
Multiple myeloma 17 0.6 0.6 18 0.6 0.5 C90
Lymphoid leukaemia 52 1.8 1.9 27 1.5 1.5 C91
Myeloid leukaemia 69 2.2 2.3 27 1.9 1.8 C92-C94
Leukaemia unspecified 37 1.4 1.5 27 0.9 0.8 C95
Other and unspecified 90 3.0 3.1 79 2.5 2.2 C26,C39,C48,C76,C80
All locations 3,063 105.9 116.5 5,133 168 155.4 C00-C96
CR: Crude rate per 100,000 people-year, ASIR: Age-standardized Incidence Rate (SEGI world population) per 100,000 people-year

Men Women
500 500

400 400

300 300
Rate per 100,000 people - year

Rate per 100,000 people - year

200 200

100 100

0 0
30 40 50 60 70 80 30 40 50 60 70 80
Age (years) Age (years)
Lung Prostate Breast Cervix

Figure 2. Specific incidence rates by age in women and men, first two locations. (Rates per 100,000 p-y). Barranquilla, 2008-2012

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Table 3. Annual average mortality due to cancer by location and gender. Barranquilla, 2008-2012
Males Females
Location n CR ASIR n CR ASIR ICD-10 Code
Oral cavity and pharynx 10 1.7 1.9 6 0.9 0.8 C00-C14
Esophagus 7 1.1 1.3 3 0.4 0.3 C15
Stomach 27 4.6 5.1 24 4.0 3.3 C16
Colon and rectum 33 5.7 6.0 49 7.9 6.7 C18-C20
Liver and bile ducts 18 3.1 3.4 23 3.7 3.1 C22
Pancreas 16 2.8 3.1 22 3.5 2.9 C25
Lung 75 13.0 14.3 49 8.1 7.1 C33-C34
Melanoma of the skin 2 0.3 0.4 2 0.2 0.2 C43
Breast 108 17.6 15.7 C50
Cervix uter 66 10.8 9.8 C53
Body of the uterus 6 0.9 2.9 C54
Ovary 21 3.4 3.1 C56
Prostate 95 16.6 17.4 C61
Bladder 7 1.3 1.3 5 0.8 0.6 C67
Lymphomas 27 4.7 5.1 24 3.9 3.5 C81-C90, C96
Leukemia 34 5.9 6.1 28 4.6 4.4 C91-C95
Thyroid 6 1.0 0.2 35 5.8 0.5 C73
Other and unspecified 24 4.1 4.4 32 5.3 4.5 C26, C39,C48,C76,C80
All locations 442 76.9 82.4 527 86.1 75.9 C00-C96
CR: Crude rate per 100,000 people-year, ASIR: Age-standardized Incidence Rate (Segi world population) per 100,000 people-year

With respect to the results of the analysis of the cases registered by the
BPCR during the 2008-2012 period, the standardized rate in women
(155.4/100,000) was higher than that of men (116.5/100,000), as it
has occurred in other places, such as Guayaquil, Ecuador, whose
Population Registry found rates of 110.0/100,000 and 146.0/100,000
for men and women, respectively, during the 2003-2006 period18,
and in Khartoum, Sudan19, which also had larger rates for women:
124.3/100,000 and 90.8/100,000, during a period similar to the one
reported in this article: 2009-2012.
On the other hand, more than 80% of the cases had pathological
confirmation, and the percentages of cases identified only by DCO
were 6.5% in men and 3.9% in women, these were values ​​lower
than the maximum suggested by the IARC20. The cancers with
higher incidence in women were: breast, cervix, colon-rectum,
thyroid, and trachea-bronchi-lung. For men, the malignant
neoplasms of higher incidence were: prostate, trachea-bronchi-
lung, colon-rectum, oral cavity, and stomach. The standardized
rate for all cancers, excluding non-melanoma skin cancer, was
116.5 per 100,000 people-years in men and 155.4 per 100,000
person-years in women.
Cervical tumors represented a significant percentage, which can
be attributed, to a large extent, to the early detection programs
in the country20, which have contributed to the inclusion of
these cancers, along with breast cancer, as an epidemiological
surveillance object 21. It is worth noting the high incidence of breast
cancer (65.7/100,000), higher than those reported for different
periods (2003-2007) by Manizales (33 / 100,000)22, Bucaramanga
(41.9/100,000)23, and Cali (48.0/100,000)24. This data is related to
mortality from this tumor, since along with Armenia, Cali, and
Bucaramanga, Barranquilla has mortality rates which are higher
than the national average: 10.525, and although mortality has
been determined chronologically before the incidence, it could
be an indicator associated with the number of cases captured by
the BPCR, which is supported by the number of cases of breast
cancer estimated for the department of Atlántico by the INC4: 481
per year, compared to an annual average of 430 captured by the
BPCR. Likewise, the percentage of DCO is low for breast cancer,
and having carried out an exhaustive review of the residence for
these tumors26, this information is validated to a great extent,
although for future studies the effect of sociocultural factors (use
of screening, self-care, etc.) environmental (climate, topography,
altitude)25 and the composition of the population, a product not
only of miscegenation, but also of groups that migrated to the area
since the nineteenth century (Arabs, Germans and English, etc.)27.
In the case of men, prostate cancer presented a rate of 43 cases
per 100,000 men-years, a value that could be considered as
intermediate when compared with Bucaramanga (50.5) and
Manizales (32.7). In this regard, it is important to mention that, in
Colombia, the Ministerio de Salud y Protecciòn Social (Ministry
of Health and Social Protection) and the  Sociedad Colombiana
de Urologìa  (Colombian Society of Urology) recommend early
detection in men over 50 years of age or under 50 years of age if
risk factors are present28, due to scientific evidence showing better
results for screening in this groups.
Regarding mortality, important differences have been found in
some departments of Colombia, such as the case of  Atlántico,
where the District of Barranquilla is located, where mortality rates
for cancer were higher than the national average4; for the 2007-
2011 period, the mortality rate standardized by age for breast
cancer per 100,000 inhabitants was 9.5 in the country, while for
the department of  Atlántico  this indicator had a value of 12.0,
only exceeded by Valle del Cauca with 12.3, while for prostate at
national level the value was of 10.5 per 100,000 inhabitants, and
for the Department it was of 14.6, occupying the second place at
the national level4.
This study finds that the rates for breast and prostate cancers
are the highest: 15.7 and 17.4 per 100,000 inhabitants in each
case, as stated by the  Análisis de Situación de Salud del Distrito
de Barranquilla  (Health Situation Analysis of the District of
Barranquilla)10, which also indicates that the mortality rate of breast
cancer has progressively increased by 2.43 points from 2004 to 2014,
while in the same period, prostate cancer’s has fallen 5.36 points.
It is noteworthy that, this study is the first to take data from
the  Sistema de Información de Cáncer en Colombia  to analyze

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mortality. This tool is available to the general public as of 2017
and is the result of the efforts of the INC and the Cancer Registries
of Colombia. Taking this source and not the DCOs of DANE
“directly”, is an interesting challenge that allows us to glimpse the
scope and potential of the information system as an important
resource for decision making in the country. Breast cancer was
found to be the leading cause of death among women, and in men,
cancer mortality was attributed mainly to prostate cancer.
Conclusions
The information obtained by the BPCR is reliable, in accordance
with the standards required by IARC, and constitutes an important
contribution to the National Information System of Cancer. The
epidemiological behavior of cancer in Barranquilla has variations
with regards to what was found and reported during the previous
years in the country, although the risk of developing cancer or
dying due to it is considered intermediate when compared with
the figures reported by other registries.
The estimates made for the 2008-2012 five-year period will serve
as a baseline for the construction of future trends. The information
generated by the BPCR provides a valuable contribution to the
construction of reliable epidemiological information for the
country, specifically in a representative city of the north coast
of Colombia, so that its sustainability must be guaranteed and
every day its objectives and strategies must be improved for both
medium and long term.
Funding:
Universidad del Norte, Instituto Nacional de Cancerología. Code
No. 0147 of 2017
Conflict of interest:
None
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Original articles

Health inequities and cancer survival in Manizales, Colombia: a population-based study

Inequidades en salud y supervivencia al cáncer en Manizales, Colombia: un estudio de base poblacional

Nelson Enrique Arias-Ortiz1, Esther de Vries2

1
Departamento de Salud Pública, Universidad de Caldas. Manizales, Colombia
2
Departmento de Epidemiologia Clinica y Biostadistica, Pontificia Universidad Javeriana. Bogotá, Colombia.

Arias-Ortiz NE, de Vries E. Health inequities and cancer survival in Manizales, Colombia: a population-based study. Colomb Med (Cali). 2018; 49(1): 63-72.
doi: 10.25100/cm.v49i1.3629

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 31 October 2017
Revised: 9 February 2018
Accepted: 13 March 2018
Keywords:
Malignant neoplasms,
survival analysis,
socioeconomic factors,
insurance, health
Palabras clave:
neoplasias malignas,
análisis de sobrevida,
factores socioeconómicos,
aseguramiento, salud
Objective: To analyze differences in survival of breast, cervical,
lung, prostate and stomach cancer by health insurance regime
(HIR) and socioeconomic position (SEP) in an intermediate city
in a middle-income country.
Methods: All patients with breast, cervix uteri, lung, prostate
and stomach cancer diagnosed between 2003 and 2007 and
characterized by the Manizales population-based Cancer Registry
(MCR) were included and followed up to a maximum of 5 years for
identifying deaths. Survival probabilities estimated by HIR were
defined according to the type of affiliation at the date of diagnosis,
and by socioeconomic stratification of residence (SS) as indicator
of SEP, stratifying for other prognostic factors using Kaplan-
Meier methods. Cox proportional hazard models were fitted for
multivariate analysis.
Results: A total of 1,384 cases and 700 deaths were analyzed. Five-
year observed survival was 71.0% (95% IC: 66.1-75.3) for breast,
51.4% (95% IC: 44.6-57.9) for cervix, 15.4% (95% IC: 10.7-20.8)
for lung, 71.1% (95% IC: 65.3-76.1) for prostate and 23.8% (95%
IC: 19.3-28.6) for stomach. Statistically significant differences
in survival by HIR were observed for breast, lung, prostate, and
stomach - with poorer survival for the subsidized and uninsured
patients. Differences by SS were observed for lung and prostate.
Differences in survival by HIR were independent of SS, and
viceversa.
Conclusions: Important inequities in cancer survival exist
related to HIR and SEP. Possible explanations include underlying
comorbidities, late stage at diagnosis, or barriers to timely and
effective treatment.
Objetivo: Analizar la supervivencia de pacientes con cáncer de
mama, cuello uterino, pulmón, próstata y estómago según régimen
de aseguramiento en salud (RAS) y posición socioeconómica (PSE)
en una ciudad intermedia de un país de medianos ingresos.
Métodos: Se incluyeron todos los pacientes con cáncer de mama,
cuello uterino, pulmón, próstata y estómago diagnosticados entre
2003 y 2007 y caracterizados por el Registro Poblacional de Cáncer
de Manizales, quienes fueron seguidos hasta un máximo de cinco
años para identificar los fallecimientos. Las probabilidades de
supervivencia estimada según RAS fueron definidas de acuerdo
con el tipo de afiliación al momento del diagnóstico, y según el
estrato socioeconómico de la residencia como indicador de PSE,
estratificando por otros factores pronósticos y utilizando el método
de Kaplan-Meier. Para el análisis multivariado se ajustaron modelos
de riesgos proporcionales de Cox.
Resultados: Se analizaron en total 1.384 casos y 700 muertes. La
supervivencia observada a cinco años fue 71.0% (IC 95%: 66.1-
75.3) para cáncer de mama, 51.4% (44.6-57.9) para cuello uterino,
15.4% (10.7-20.8) para pulmón, 71.1% (65.3-76.1) para próstata,
y 23.8% (19.3-28.6) para estómago. Se observaron diferencias
estadísticamente significativas en la supervivencia según RAS para
mama, pulmón, próstata y estómago, con supervivencia más pobre en
los pacientes del régimen subsidiado y no asegurados. Se observaron
diferencias por estrato socioeconómico en los cánceres de pulmón y
próstata. Las diferencias por RAS fueron independientes del estrato
socioeconómico y viceversa.
Conclusiones: Existen importantes inequidades en la supervivencia de
pacientes con cáncer relacionadas con el RAS y con la PSE. Las posibles
explicaciones incluyen comorbilidades subyacentes, diagnóstico tardío
y barreras para el acceso al tratamiento oportuno y efectivo.

Corresponding author:
Nelson Enrique Arias-Ortiz. ORCID: Carrera 25 Nº 48-57, Manizales, Caldas,
Colombia,. Sede Versalles Universidad de Caldas. Phone: +57 (6)8783060 ext
31255; +573125836563. https://orcid.org/0000-0001-5093-3384. E-mail: nelson.
arias@ucaldas.edu.co

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Introduction
Socio-economic differences in cancer survival have been well
documented in the last two decades1. Disparities in stage at
diagnosis have been considered as the main underlying factor
of those differences. However, there is evidence that differential
access to timely and adequate treatment by socio-economic groups
also determines cancer survival inequities1. Estimations of relative
risk of dying comparing the most deprived groups with the best-off
groups have been around 1.3 to 1.5-fold; factors underlying these
differences include tumour- and patient conditions, and access
to and quality of care1. In countries with universal health care
insurance like Canada, socioeconomic position (SEP) remained
associated with cancer survival, the differences are not being
due to stage at diagnosis2. Inequalities and inequities have been
reported for all cancer sites combined1, but also for specific sites
including breast3, cervix4, lung5, prostate6 and stomach7,8 cancers.
For breast and cervical cancer, large differences were observed
between developed and developing countries but also between
developed countries and within countries9. For female cancers,
place of residence, income, socioeconomic and educational level,
ethnicity, and migration status have been associated with inequities
in survival9.
In Colombia, health insurance financed through contributions of
both workers and employers (contributory regime) is mandatory
for dependent employees and partially voluntary for independent
workers. A small proportion (<5%) of the population, working in
certain public sectors, has exceptional or special health insurance
plans (special or exceptional regime). The poor population is
covered by a subsidized health system founded through taxes
(subsidized regime)10. In 2005, contributory and subsidized
regimes covered 36.3% and 43.3% of the population, respectively,
while about 20% of population had no health insurance11. In
theory, special and contributory regimes offer the best access to
care, but in practice special/exceptional regimes have shown some
problems that could make the conditions of its affiliates worse than
those of the contributory regime12,13. Recent laws (years 201114 and
201515) have advocated for universal health care access without
differences by SEP. However, those legislative changes have not
been fully implemented, and patients diagnosed prior to 2010 may
have experienced different survival rates depending on their health
insurance status and their SEP. Large socioeconomic disparities in
gastric cancer survival were recently documented in other cities in
Colombia, despite improvements in health insurance coverage 8 and
therefore it is not surprising that large inequities in population-
based cancer mortality exist17,18. Hardly any population-based
information by socioeconomic indicators is available for other
cities and other cancers in Colombia.
Manizales is a middle-size Andean city in Colombia with a projected
population in 2005 (mid-term year) of 379,794 inhabitants 18. Since
2003, the city hosts a population-based cancer registry that meets
international standards proposed by IARC19  and has reported
incidence rates that are slightly higher than national estimations,
mainly for breast, lung and stomach cancers20,21 - coinciding with
a higher smoker rate and position in the Andes. With incidences
known, there is a need to evaluate population-based survival for
this population, and evaluate the effect of health insurance and SEP
on its survival rates. The aim of this paper is to analyze differences
64
in breast, cervical, lung, prostate and stomach cancer survival
as a result of health insurance and socioeconomic status in this
intermediate, Andean city in Colombia.
Materials and Methods
Type of study
Exploratory population-based cohort study.
Patients and follow up
All 1,482 patients resident in Manizales with breast, cervix uteri,
lung, prostate or stomach cancer diagnosed between 2003 and
2007 and characterized at baseline by Manizales’ Cancer Registry
- MCR (information regarding data quality of MCR was published
previously19,22) were included: 380 female-breast cancer cases
(5 male cases were excluded), 226 cervix uteri, 230 lung, 296
prostate, and 347 stomach cancer patients. The percentages of
microscopically verified cases were 95.8%, 96.9%, 78.6%, 92.5% and
89.4% for breast, cervix, lung, prostate, and stomach, respectively.
All cases were followed up until 60 months or until December 31th
2013 since diagnosis for identifying the event of study (deaths due
to all causes) and time to event through matching personal identity
numbers and names of incident cases with the local vital statistics
provided by the local health authority; also, we performed manually
searching in electoral rolls and health insurance databases. Active
follow-up was performed by consultation of medical records where
available. When only data for year was available, month and day
were assigned to June 30th. Patients without event were censored
at five years of follow-up. Subjects were considered alive if they
were eligible to vote or if they were reported as “active” in health
insurance databases on December 31th 2013. Survival time was
calculated as the difference between incidence date and date of
death, date of last contact with health system, date of loss to follow
up, or date they were censored. For incidence data, MCR uses rules
from European Network of Cancer Registries23.
Sixteen subjects with a clinical cancer diagnosis were lost to follow
up at day of diagnosis and were therefore treated the same as DCO
cases. There were 77 cases identified only by their death certificate
(DCO), representing 5.2% of all cases (breast: n= 5 (1.3%); cervix
uteri: n= 5 (2.2%); lung: n= 29 (12.6%); prostate: n=19 (6.4%)
and stomach: n=19 (5.5%). According to international registry
standards, a case is flagged as DCO when death certificate is the
only source of data for the case, i.e, there is no other data from
pathological reports, medical images, or hospitals. Since DCO
cases by definition do not have information about time to event,
they were excluded from survival analyses.
Clinical and demographic characteristics
Information on histological subtype coded according to the
International Classification of Diseases for Oncology, 3rd revision
-ICDO-3- was available for 95.2% of cases; clinical stage at diagnosis
according to TNM system was available in usable proportions of
patients only for breast (62%) and cervix (42%) cancer. For other
sites, clinical stage was available in less than 30% of cases and could
therefore not be used. There were no patients with missing data
for age at diagnosis. More than 85% of patients had complete date
of birth, and their ages in clinical records were consistent with
calculated ages. For patients without date of birth, age in clinical
records was assumed as correct.
 Arias-Ortiz NE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
Differences in diagnostic methods were observed only for
prostate and stomach cancers, which “only clinical” and “clinical
procedures” methods were observed only for patients in
contributory and subsidized regimes and uninsured, while 100%
of the cancers diagnosed in patients affiliated to the special regime
were histologically confirmed.
Socioeconomic indicators
Variables for socioeconomic position and health insurance were
defined following categories previously used for a Colombian
population by de Vries et al8. Socioeconomic stratum (SS) of the
place of residence at diagnosis was used as indicator of SEP. In
Colombia, SS is defined according to external and internal physical
characteristics of dwellings and wards, ranging from the purely
functional and indispensable to the aesthetic, ornamental and
sumptuous characteristics. SS is reported in categories from 1 to
6, where 1 and 2 corresponds to “low” social stratum, 3 and 4 to
“middle”, and 5 and 6 to “high”.
Health Insurance Regime (HIR) at the date of diagnosis was used
grouping the special and exceptional regimes into one unique
category, contributory regime, subsidized regime, and a group of
uninsured people.
Statistical analysis
Observed survival proportions at different times were obtained
using Kaplan-Meier analyses, stratifying analyses by HIR and SS,
age, sex, histological subtype and, for breast and cervical cancer
only, clinical stage at diagnosis. Cox multivariate proportional
hazard assumption was checked by visual evaluation of log-log
plots; the assumption was not violated. Three Cox multivariate
regression models for each cancer were fitted for both HIR and SS:
i) a univariate (null) model; ii) a multivariate model A with age, sex
(lung and stomach), histological subtype, and clinical stage (breast
and cervix) as covariates ; and iii) a model B containing all variables
of model A plus an additional term for SS in the HIR model and
vice versa8. All calculations were performed using STATA™ SE 12.0.
Ethical considerations
This research was approved by the Research Ethics Committees of
the Universidad del Valle, Universidad de Caldas, and the National
Cancer Institute of Colombia.
Results
Patient and tumour characteristics for all 1,405 incident cases are
shown in Supplementary Table 1S.
For the five cancer sites studied, 1,384 cases were finally analyzed.
Lost of follow-up was 1.7% for five sites studied (0.8% for breast,
2.3% for cervix, 1.9% for lung, 1.8% for prostate, and 2.1% for
stomach). In Manizales, HIR coverage among cancer patients was
88.8%, except for gastric cancer, in which 18.3% had no affiliation
to HIR. Breast and prostate patients without HIR tended to be older
at diagnosis than affiliated, but differences were not statistically
significant.
At five-years follow-up, 700 deaths (all causes) were observed.
Mean follow-up time for overall sites was 38.4 months (95% CI:
37.2; 39.7), varying from 18.5 months for lung to 50.8 months for
breast cancer. Five-year observed survival (OS) was 49.1% (95%
65
CI: 46.4-51.7) for the five sites combined. By cancer site, 5-year OS
were 71.0% (95% IC: 66.1-75.3), 51.4% (95% CI: 44.6-57.9), 15.4%
(95% CI: 10.7-20.8), 71.1% (95% CI: 65.3-76.1) and 23.8% (95%
CI: 19.3-28.6) for breast, cervix uteri, lung, prostate, and stomach,
respectively (Table 1).
Statistically significant differences in survival by HIR were
observed for breast, lung, prostate, and stomach - with poorer
survival for the subsidized and uninsured patients. Differences by
SS were observed for lung and prostate. (Figs. 1 and 2). One and
five-years OS proportions were significantly lower in uninsured
or subsidized patients versus patients with special or contributory
HIR, with exception of cervix uteri cancer. Regarding SS, differences
statistically significant were only observed in lung and prostate
cancers, with poorer survival proportions in patients for low/
middle versus high SS and low versus middle/high SS, respectively.
However, survival proportions for cervix uteri and lung cancer of
patients affiliated to the special/ exceptional HIR were lower than
in the other categories, even lower than in uninsured population.
As expected, overall survival was higher in younger patients for all
sites studied, but those differences were not statistically significant.
According to literature, clinical stage at diagnosis showed a strong
association with survival (Table 1 and Fig. 3). Survival was better
for women diagnosed with ductal breast carcinoma vs. other
histological subtypes. Non-significant differences in survival
were observed by histological subtypes of cervix, lung, prostate
and stomach cancers. For lung and stomach cancers no survival
differences by sex were observed.
Table 2  shows results from Cox models by HIR and SS and by
cancer site. For prostate cancer, HIR hazard ratios (HR) remained
significant after adjusting for age and histological subtype, with
lower hazard of dying for special HIR group in comparison with
the subsidized regime (HR: 0.17 (95% IC: 0.04-0.80)). These results
remained significant in multivariate analyses. For stomach cancer,
patients in contributory regime had better survival in all, univariate
and multivariate, models, with about 30% lower hazard of dying
in comparison with patients in subsidized HIR. With respect to
socioeconomic position, prostate cancer patients from middle SS
showed about 47% lower hazard of dying than patients from low
SS (HR 0.53, 95% CI: 0.31-0.88), independently of health insurance
regime. Other sites did not reach statistical significance, possibly
due to the low number of cases in each group.
Unsurprisingly, advanced clinical stages for breast and cervix had
increased HRs. In line with the Kaplan-Meier results, cervical
cancer patients affiliated to the special regime had a higher hazard
than women affiliated to the subsidized regime after adjusting by
age, histological subtype and clinical stage.
Model B showed that inclusion of both terms HIR and SS in the
same model modified HR estimates in all cancers combined and
by cancer site, indicating independent effects of HIR and SS on
survival.
Discussion
This population-based study on population-based survival for
five cancer sites in Manizales, Colombia, demonstrated significant
differences in observed survival. Differences by HIR varied from 8
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Table 1. Survival estimations by cancer site and prognostic factors. Manizales, 2003-2013
Proportion surviving after (%)
Cases (n) Deaths (n) WBG test*
12 m 36 m 60 m
All cases 375 108 93.8 81.0 71.0
Age at diagnosis
0 a 49 116 29 96.5 85.2 74.8 X2=1.63
50+ 258 79 92.6 79.1 69.3 p=0.20
Histology
Breast Ductal Ca. 307 82 95.1 83.1 73.3 X 2 =6.19
Other and NOS 67 26 87.9 71.2 60.4 p=0.013
Clinical stage
Stage I 25 0 100.0 100.0 100.0 X 2 =80.76
Stage II 97 5 100.0 96.9 94.9 p=0.000
Stage III 82 19 100.0 89.0 76.8
Stage IV 29 11 93.1 69.0 55.2
Unknown 141 71 85.0 64.3 49.2
All cases 220 105 80.7 62.1 51.4
Age at diagnosis
0 a 49 101 42 83.0 68.0 58.0 X2=2.40
50+ 119 63 78.7 57.1 45.8 p=0.121
Histology
Squamos cell Ca. 167 80 80.1 60.7 51.6 X2= 1.99
AdenoCa. 38 16 83.9 70.3 56.8 p=0.369
Cervix
Other and NOS 15 9 79.4 57.8 36.1
Clinical stage
Stage I 16 2 100.0 93.8 87.5 X 2 = 13.75
Stage II 36 16 91.7 69.4 55.6 p=0.008
Stage III 30 19 80.0 53.3 36.7
Stage IV 13 10 69.2 38.5 23.1
Unknown 125 58 76.3 60.5 52.2
All cases 198 165 43.6 21.0 15.4
Sex
Women 81 67 50.6 28.4 17.3 X2= 3.25
Men 117 98 38.7 15.8 14.1 p=0.071
Age at diagnosis
0 a 59 59 46 40.7 27.1 22.0 X2=0.94
Lung
60+ 139 119 44.9 18.4 12.5 p=0.331
Histology
Squamous cell Ca. 71 54 49.3 22.5 16.9 X2=5.96
AdenoCa. 53 44 37.3 17.7 13.8 p=0.113
Small cell Ca. 16 13 56.3 31.2 18.7
Other and NOS 58 49 38.6 19.3 14.0
All cases 270 78 92.2 78.9 71.1
Age at diagnosis
0 a 59 43 8 95.4 83.7 81.4 X2=2.05
Prostate 60+ 227 70 91.6 77.8 69.2 p=0.152
Histology
Adeno Ca. 257 70 92.3 79.4 72.2 X2=2.30
Other and NOS 18 8 83.3 72.2 55.6 p=0.129
All cases 322 244 49.4 33.1 23.8
Sex
Women 114 83 57.6 39.0 26.6 X2=1.31
Men 208 161 44.9 30.0 22.2 p=0.252
Age at diagnosis
0 a 59 112 86 48.2 32.1 23.2 X2=0.03
Stomach
60+ 210 158 50.0 33.7 24.1 p=0.857
Histology
Adeno Ca, intestinal 146 111 54.5 33.8 23.5 X2=2.01
Difuse Ca. 73 59 41.7 26.4 18.1 p=0.569
Adeno Ca., others 48 35 47.9 37.5 27.1
Other and NOS 55 39 47.3 36.4 29.1
NOS: Non other specification *WBG: Wilcoxon -Breslow-Gehan test.

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Breast Cerviz uteri

1.00

1.00
0.75

0.75
Survival proportion

Survival proportion
0.50

0.50
0.25

0.25
WBG test = 9.6; p=0.035 WBG test = 6.1; p=0.108

0.00

0.00
0 20 40 60 0 20 40 60
Months Months
Special Contributory Special Contributory
Subsidized Not insurance Subsidized Not insurance

Lung Prostate

1.00
1.00
WBG test = 12.7; p=0.005

0.75
0.75

Survival proportion
Survival proportion

0.50
0.50

0.25
0.25

WBG test = 7.9; p=0.048

0.00
0.00

0 20 40 60 0 20 40 60
Months Month
Special Contributory Special Contributory
Subsidized Not insurance Subsidized Not insurance

Stomach
1.00

WBG test = 9.9; p=0.019

0.75
Survival proportion
0.50
0.25
0.00

0 20 40 60
Months
Special Contributory
Subsidized Not insurance

Figure 1. Observed survival by health insurance regime and cancer site. Manizales, 2003-2013. WBG:
Wilcoxon-Breslow-Gehan test.
Breast Cervix uteri
1.00
1.00

0.75
0.75
Survival proportion

Survival proportion
0.50

0.50
0.25

0.25

WBG test= 2.6; p=0.27

WBG test = 1.6; p=0.44
0.00

0.00

0 20 40 60 0 20 40 60
Months Months
High Intermediate Low High Intermediate Low

Lung Prostate
1.00
1.00

WBG test = 6.5; p=0.039

0.75
0.75

Survival proportion
Survival proportion

0.50

0.50
0.25

0.25

WBG test = 7.2; p=0.027

0.00

0.00

0 20 40 60 0 20 40 60
Months Months

High Intermediate Low High Intermediate Low

Stomach
1.00

WBG test = 3.2; p=0.198

0.75
Survival proportion
0.50
0.25
0.00

0 20 40 60
Months
High Intermediate Low

Figure 2. Observed survival by social strata and by cancer site. Manizales, 2003-2013. WBG:
Wilcoxon-Breslow-Gehan test.

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 Arias-Ortiz NE/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
percent-points in stomach to 32 percent-points in prostate cancer.
Hazard Ratios estimated for HIR were in line with risks reported
in other studies1. Absolute differences by SS were less noticeable,
with differences between low versus high categories of about 16
percent-points for prostate, 10 for breast, 14 for cervix, 5 for lung,
and 11 percent-points for stomach cancers. The magnitude of these
disparities is similar with those found in U.S for the last quarter of
the past century24.
Colombian health system was radically reformed at the end of
the last century, resulting in a substantial increase in coverage of
health insurance which reached almost 100% around 2010. On
paper, this meant a substantial improvement in access to health
services. However, timely access to health care in cancer diagnosis
and treatment is still problematic, particularly because of the high
out-of-pocket cost and long waiting times to obtain permission to
use these services. In Colombia, access to health care is differential
according to the health insurance regime, and inequities persist
between types of affiliation. Local researchers have pointed out that
universality in National Health System has not been achieved and
there has been a stagnation in matters regarding access to services
and equality25. Additionally, enormous regional disparities have
been described in Colombia, and the country has one of the worst
distributions of per capita income in the world26.
1.00
0.75
Survival proportion
0.50
0.25
0.00
0 20
Stage I
1.00
0.75
Survival proportion
0.50
0.25
0.00
0 20
Stage I
Figure 3. Survival proportion by clinical stage at diagnosis for breast cancer (based on 233 cases
with known clinical stage) and cervix uteri cancer (based on 95 cases). Manizales, 2003-2013.
68
In general, 5-year OS by site was below that observed for most
countries in the CONCORD27  and EUROCARE28  studies.
Disparities by HIR and SS for breast, prostate and stomach cancers
were similar to reported by literature29-33.
The survival proportion for women with a cancer of the cervix uteri
was 3-fold lower among women affiliated to the special regime
compared to the other HIR groups. This surprising results - special
regimes have, in theory, the most generous health care plan - are
in line with the observation of the worst stage at diagnosis in this
group, which suggest that screening and early detection programs
are not properly working in special regime entities. Regarding
socioeconomic stratification, survival rates or cervical cancer were
7 and 14 percent-points higher in low and middle social strata,
respectively, in comparison with the richest group. Incidence rates
were lower in the richest group, and the relative low frequency of
disease among the wealthiest part of the population may result in
a lower awareness or lower participation rates in screening and
early treatment programs for cervical cancer. However, differences
in clinical stage at diagnosis did not reach statistical significance -
perhaps because number of cases in the high strata was very low
(see supplementary table). In this regard, Brookfield et al.34, found
that, in women living in the state of Florida (USA), the independent
predictors of poorer outcomes were insurance status, tumor stage,
tumor grade, and treatment. Neither race, nor ethnicity, nor SES
Breast
40 60
Months
Stage II Stage III Stage IV
Cervix uteri
40 60
Months
Stage II Stage III Stage IV
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Table 2. Proportional risks (Cox) survival models by cancer site.

Univariate analysis Multivariate analysis
Model A Model B
HR IC 95% HR 95% CI HR 95% CI
Health insurance *
Contributory 0.77 0.47-12.7 0.71 0.43-1.17 0.77 0.44-1.36
Special 0.89 0.38-2.09 0.47 0.20-1.13 0.52 0.20-1.34
Not insured 1.66 0.84-2.26 1.27 0.64-2.55 1.41 0.65-3.07
Breast cancer Cases (events) 370 (108) 370 (108) 345 (99)
Social Strataa
Middle 0.88 0.57-1.35 0.75 0.48-1.17 0.93 0.56-1.55
High 0.61 0.33-1.14 0.65 0.35-1.21 0.84 0.42-1.65
Cases (events) 347 (99) 347 (99) 345 (99)
Health insurance *
Contributory 0.78 0.51-1.22 1.76 0.85-3.64 2.12 0.99-4.55
Special 2.20 0.85-5.68 5.02 1.69-14.9 7.60 1.94-29.7
Not insured 0.92 0.46-1.81 0.94 0.25-3.58 0.90 0.23-3.51
Cervical cancer Cases (events) 217 (104) 92 (46) 87 (43)
Social Strataa
Middle 0.78 0.50-1.22 0.91 0.47-1.76 0.67 0.32-1.41
High 1.20 0.55-2.62 0.84 0.19-3-65 0.38 0.08-1.87
Cases (events) 197 (95) 88 (44) 87 (43)
Health insurance *
Contributory 0.69 0.47-1.02 0.75 0.51-1.12 0.89 0.58-1.36
Special 1.15 0.61-2.19 1.22 0.64-2.32 1.28 0.66-2.49
Not insured 1.04 0.54-2.01 1.32 0.66-2.62 1.77 0.83-3.77
Lung cancer Cases (events) 197 (165) 197 (165) 186 (157)
Social Strata a

Middle 1.00 0.72-1.39 0.99 0.71-1.38 1.03 0.74-1.46

High 0.58 0.32-1.05 0.60 0.33-1.09 0.67 0.36-1.24
Cases (events) 186 (157) 186 (157) 186 (157)
Health insurance *
Contributory 0.58 0.28-1.21 0.56 0.27-1.18 0.56 0.26-1.21
Special 0.17 0.04-0.80 0.20 0.04-0.95 0.12 0.02-0.99
Not insured 0.89 0.33-2.37 0.74 0.27-2.02 0.81 0.27-2.41
Prostate cancer Cases (events) 266 (77) 266 (77) 233 (70)
Social Strataa
Middle 0.52 0.31-0.87 0.53 0.31-0.88 0.54 0.32-0-92
High 0.63 0.32-1.26 0.71 0.36-1.44 0.78 0.38-1.60
Cases (events) 237 (71) 237 (71) 233 (70)
Health insurance *
Contributory 0.72 0.52-0.98 0.71 0.52-0.98 0.70 0.51-0.98
Special 0.70 0.36-1.38 0.72 0.36-1.41 0.75 0.38-1.50
Not insured 0.93 0.62-1.39 0.93 0.62-1.39 1.01 0.65-1.56
Stomach cancer Cases (events) 320 (243) 320 (243) 289 (221)
Social Strataa
Middle 0.80 0.61-1.06 0.80 0.60-1.05 0.82 0.62-1.09
High 0.75 0.46-1.20 0.76 0.47-1.23 0.89 0.55-1.45
Cases (events) 291 (222) 291 (222) 289 (221)
* Subsidized regime as reference a Low strata as reference. Models were adjusted by age, sex (lung and stomach), histological subtype, and stage at diagnosis (breast and cervix).

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was an independent predictor of poorer outcome. Similarly, Niu et
al.35, found no significant differences in cervical cancer survival by
insurance status in New Jersey.
For lung cancer, 2.3 and 2-fold better survival rates were observed in
patients from contributory, subsidized and non-insured categories
in comparison with special regimes. These results are contradictory
with those reported in US36 where uninsured and Medicaid patients
had poorer survival than patients with private insurance. This
pattern may be reflecting barriers to early diagnosis and treatment in
this subgroup, which in Manizales is mostly composed by teachers,
and army and police members. However, this should be confirmed
by studies with a larger number of patients. Survival proportions
were around five percent-points lower in the lowest socioeconomic
stratum in comparison with the most affluent group, which is
consistent with figures reported by Ou et al37.
Disparities in cancer survival related to the health system can
be attributed to barriers and delays in obtaining diagnostic care,
associated with more advanced stages at diagnosis. In Colombia,
practically all medical procedures require authorization from the
insurer, which in many cases lead to substantial diagnostic and
treatment delays and - consequently - to more advanced stages in
diagnosis and poorer outcomes38,39. Therefore, many people turn
to the out-of-pocket payment of some services to avoid delays,
but people with low financial resources have no other avenues for
access to timely diagnosis and treatment and are subject to the
administrative procedures of their insurers.
Strengths and weaknesses
The population-based nature of this work minimizes selection
biases in the estimates and serves as a tool for policy-makers to
evaluate access and quality of care. Although numbers of patients
are relatively small due to the small population size of Manizales,
estimates are sufficiently robust to discern general patterns.
A major limitation of this study is the lack of relative or net
survival estimations by HIR and SS due to lack of available data
on population numbers and life-tables by those variables. The
registry had no access to the cause of death, making it impossible
to calculate cause-specific survival. For cancers with a very poor
prognosis, this is not so problematic as most patients will die due to
their cancer. However, for cancers with a relatively good prognosis
(e.g. breast and prostate), a substantial proportion of deaths may
have been due to other causes of death. Considerable proportions
of cases had unknown data about SS, specially for cervix, prostate
and stomach cancers (12.2%, 13.1% and 11.0%, respectively). In
addition, the percentage of cases with missing data for clinical
staging at diagnosis was high for all cancers, except breast and
cervical cancer: more than 70% of lung, prostate and stomach
cancer cases had no stage information, impeding including this
variable in the multivariate analyses. The number of cases was
very low in some cancer sites and affected multivariate analysis.
Around 5% of patients were excluded from analyses because they
had no follow-up time (DCO cases and lost-to-follow-up at date
of diagnosis), which theoretically could influence findings, as
more DCO cases are expected among the lower socioeconomic
groups. However, a recent paper showed that, even though DCO
diagnosis is associated with low SS, exclusion or inclusion of DCO
cases had no significant impact of hazard ratios for survival by
socioeconomic variables40.
70
Conclusions
Important inequities in cancer survival exist in Manizales related
to health insurance and socioeconomic position. Differences may
be attributed to inequities in comorbidities, stage at diagnosis,
or barriers to timely access to effective treatment suggested by
differences observed between health insurance regimes.
Acknowledgements:
We would like to thank the Local Health Authority in Manizales
for providing death data, and to the National Cancer Institute for
the technical and financial support to this research. To Manizales’
Cancer Registry staff for the cooperation to complete data, and all
the sources of MCR for allowing data query. To medical institutions
in Manizales for their cooperation in data collection.
Funding:
This study was funded by the National Cancer Institute of Colombia
and University of Caldas through inter-administrative contract
number 0365-2014.
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 Uribe PCJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original article

Cancer incidence and mortality in Bucaramanga, Colombia. 2008-2012

Incidencia y mortalidad por cáncer en Bucaramanga, Colombia. 2008-2012

Claudia Janeth Uribe Pérez1,2, Sergio Eduardo Serrano Gómez4, Claudia Milena Hormiga Sánchez3

1
Grupo de investigación Estudio Genético de Enfermedades Complejas, Universidad Autónoma de Bucaramanga. Bucaramanga, Colombia.
2
Directora del Registro Poblacional de Cáncer del Área Metropolitana de Bucaramanga. Bucaramanga, Colombia.
3
Grupo de investigación Observatorio de Salud Pública de Santander, Fundación FOSCAL- Universidad Autónoma de Bucaramanga. Bucaramanga, Colombia
4
Grupo de investigación Investigaciones Clínicas UNAB, Universidad Autónoma de Bucaramanga. Bucaramanga, Colombia

Uribe PCJ, Serrano GSE, Hormiga SCM. Cancer incidence and mortality in Bucaramanga, Colombia. 2008-2012. Colomb Med (Cali). 2018; 49(1): 73-80.
doi: 10.25100/cm.v49i1.3632.

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history Abstract Resumen

Received: 5 November 2017
Revised: 16 January2018
Accepted: 15 March 2018
Keywords:
Cancer, incidence, mortality,
Records, Bucaramanga.
Palabras clave:
Cáncer, incidencia,
mortalidad, registros,
Bucaramanga.
Introduction: Cancer is a huge burden worldwide, especially for the
least developed countries. Population-based cancer registries (PB­CRs)
are essential to know the cancer territorial profiles and the evaluation of
the impact of their control programs.
Aim: To estimate the cancer incidence and mortality in the Metropolitan
Area of Bucaramanga over the period 2008-2012.
Methods: A descriptive study of cancer incidence and mortality was
conducted in the Metropolitan Area of Bucaramanga. The cases of
primary invasive cancer from the period 2008-2012 were obtained from
the base of the Population Registry of Cancer of the Metropolitan Area
of Bucaramanga. The National Administrative Department of Statistics
provided population and death data. Crude rates of global and specific
incidence and mortality were estimated for each sex, and standardized
incidence and mortality rates.
Results: During the five-year period, 8,775 incidents cases of cancer
were recorded (excluding non-melanoma skin cancer). The global
standardized incidence rate was 151.7 per 100,000 men-year and 157.2
per 100,000 women-year. The main locations were prostate, stomach
and colorectal men in men, and breast, thyroid and colorectal in women.
The standardized mortality rate by sex was 94.8 per 100,000 men-year
and 78.0 per 100,000 women-year.
Conclusion: For the most part of neoplasms, the incidence and
mortality rates in the Metropolitan Area of Bucaramanga are lower than
the rates reported in Colombia and Metropolitan Area of Bucaramanga
in the five-year period 2003-2007, except for colorectal cancer, thyroid
cancer and leukemia showing a tendency to increase, which requires
further investigation.
Introducción: El cáncer constituye una carga en el mundo, en especial
para los países menos desarrollados. Los Registros Poblacionales de
Cáncer son fundamentales para conocer los perfiles territoriales del
cáncer y la evaluación del impacto de sus programas de control.
Objetivo: Estimar la incidencia y mortalidad por cáncer en el Área
Metropolitana de Bucaramanga en el período 2008-2012.
Métodos: Se realizó un estudio poblacional descriptivo de la incidencia
y mortalidad por cáncer en el Área Metropolitana de Bucaramanga. Los
casos de cáncer invasivos primarios del periodo 2008-2012 se obtuvieron
de la base del RPC-AMB. Los datos de población y defunciones fueron
facilitados por el Departamento Administrativo Nacional de Estadística
(DANE). Se estimaron tasas crudas de incidencia y mortalidad globales
y específicas por sexo, y tasas de incidencia y mortalidad estandarizadas.
Resultados: Durante el quinquenio se registraron 8,775 casos incidentes
de cáncer (excluyendo cáncer de piel no melanoma). Las tasas de
incidencia estandarizada globales por 100,000 personas-año fueron
de 151.7 en hombres y 157.2 en mujeres. Las principales localizaciones
fueron próstata, estómago y colorrecto, en los hombres, y mama,
tiroides y colorrecto en las mujeres. La tasa de mortalidad estandarizada
por 100,000 personas-año fue de 94.8 en hombres y de 78.0 en mujeres.
Conclusión: Las tasas de incidencia y mortalidad en la mayoría de
localizaciones son inferiores a las nacionales y al quinquenio previo en el
Área Metropolitana de Bucaramanga. El cáncer de tiroides, colorrectal,
y las leucemias muestran una tendencia al aumento, lo cual demanda
indagaciones posteriores.

Corresponding author:
Claudia Janeth Uribe Pérez. Universidad Autónoma de Bucaramanga.
Av. 42 #48 – 11. E-mail: curibep@unab.edu.co
73
 Uribe Pérez CJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
Introduction
Cancer represents a huge burden in the world, causing about 14.1
million new cases and 8.2 million deaths in 2012. The burden of cancer
is increasing in less developed countries, from which about 57% of the
new cases come up as well as 65% of the deaths caused by this disease.
It is estimated that 48% of prevalent cases of cancer at five years of
diagnosis occur in the regions with less economic development1,2.
The incidence of cancer is increasing. It is expected that by 2025,
there will be more than 20 million new cases, and a greater burden
in low and middle income countries3,4. This trend is attributed to
the growth and aging of the population, as well as to a growing
prevalence of clearly established risk factors, such as smoking,
overweight, physical inactivity and changes in reproductive patterns
associated with urbanization and economic development1,2.
To generate impact on the reduction of the problems generated by
this disease, the World Health Organization (WHO) promotes the
creation of effective programs that improve early detection, timely
diagnosis, and a specific and effective treatment5.
It also leads cancer control programs with the promotion of
national cancer control policies, plans and programs. One of the
strategies has been the promotion, establishment and strengthening
of the monitoring and evaluation of this disease through registries,
as well as research aimed at the burden of the disease, as well as
increasing the availability of resources for its care6.
Population Cancer Registries (RPC, for its initials in Spanish) are
essential information systems for cancer control programs; these
allow determining frequencies, incidences, mortality and trends,
which are the result of activities aimed at collecting, analyzing
and continuously disseminating information on cancer cases that
occur in a specific population, with guarantee of the quality of the
data (completeness, precision, and comparability)7,8.
In Colombia there are four RPC with international recognition. One
of these is the Population Registry of Cancer of the Metropolitan Area
of ​​Bucaramanga (RPC-AMB), which has managed to consolidate a
continuous work during 18 years of operation9,10.
With the leadership of the Ministry for Health and Social
Protection, the National Cancer Information System was set up
and the National Cancer Observatory for Colombia was created,
led by the National Cancer Institute of Colombia (INC, for its
initials in Spanish), in order to know the territorial profile and
evaluate the impact of cancer control programs11. Population
Cancer Registries are a fundamental part of this initiative  12;
through them, the epidemiology of the disease can be known; and
also the rate progress is being made in terms of fulfilling one of the
pillars of the Ten-Year Plan for Cancer Control13.
This study describes the total and specific incidence and
mortality rates by sex, corresponding to the Metropolitan Area of​​
Bucaramanga during the period 2008-2012.
Materials and Methods
A descriptive population study was proposed, with the incident
cases of invasive cancer registered in the databases of the RPC-
AMB in the quinquennium 2008-2012.
74
Geographic area
Metropolitan Area of ​​Bucaramanga is a geographical area made up
of four municipalities in the province of Santander: Bucaramanga
(its capital city), Floridablanca, Girón and Piedecuesta. It is
located in the Andean region and it has an area of ​​1,479 km2. Each
municipality is independent in its political organization, but they
are completely related from an economic and social perspective14.
According to population projections of DANE, AMB had 1,074,000
inhabitants at the middle of the 2008-2012 period (53.5% of the
provincial total); 94.3% were urban residents, 51.9% were women,
24.5% were aged under 15 years, and 20.4% were older than 50
years15.
AMB is an important reference center for the care of cancer patients
in the northeastern part of the country, with state (hospitals) and
private institutions (clinics, specialized medical centers, diagnostic
centers, oncology centers and medical specialists in all areas) that
provide various oncological services for diagnosis and treatment.
The Population Registry of Cancer of the Metropolitan Area of​​
Bucaramanga (RPC-AMB)
RPC-AMB has carried out permanent activities since April 2000, as
a result of the commitment assumed by La Universidad Autónoma
de Bucaramanga).  The economic resources are assigned in the
research calls of the university, and it receives annual co-financing
from the INC.
Method of data collection and processing
RPC-AMB makes active collection of incident cases through
periodic visits to information sources: pathology and hematology
laboratories, hospital discharges, imaging centers, screening
centers, volunteer programs, oncology centers, medical specialists,
autopsies and certificates of deaths that are obtained in the
Provincial Health Secretariat.
A recordable case is any malignancy of any location including
benign neoplasms of the Central Nervous System (CNS) and
carcinomas in situ that have been diagnosed after January 1 of
the year 2000 in residents of AMB, both in urban and rural areas,
regardless of the diagnostic method used, so that cases identified
by death certificate are also included. It excludes non-melanoma
skin cancer (basal cell and squamous cell).
The cases obtained by hospital discharge and death certificates
follow a process of verification of the diagnosis, through the search
of the clinical history. When no additional information is obtained
from the case obtained by the death certificate, it is recorded as a case
identified only by its death certificate (death certificate only - DCO).
The coding of cancer cases is carried out under the supervision
of the RPC Director, by personnel trained in the International
Classification of Diseases for Oncology (ICD-O) - 3rd edition, 1st
revision, published by the World Health Organization (WHO) ) in
2013, and the IARC criteria for multiple primary tumors16,17.
RPC-AMB complies with confidentiality standards following the
parameters of the IARC and the research commitment ethics.
Only the staff of RPC-AMB accesses the information of each case,
which allows exhaustive work in the control of the duplicity of the
information8,18.
 Uribe Pérez CJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
The source of information on deaths was DANE, the official entity that
collects, organizes and codifies the basic causes of mortality using the
tenth revision of the International Classification of Diseases (ICD 10)19.
The CanReg5 program20, designed for the RPC by the IARC, was
used to systematize the information of the incident cases, which
allows eliminating duplicates and identifying multiple primary
tumors. Additionally, the data is also validated with the IARC
Tools and Registry Plus™ Link Plus programs20,21.
For the estimation of the incidence rates, the population of the
AMB of the study period, projected by DANE, was used as the
denominator. Crude and standardized rates were calculated by
direct method using the global standard population proposed by
Segi and corrected by Doll22. The analyses were performed in Stata
1423 and the program CanReg5©, version 5.00.42, software created
by the International Agency for Research on Cancer (IARC),
in collaboration with the International Association of Cancer
Registries (IACR), available for free all members of the IACR24.
Results
During the 2008-2012 quinquennium, there were 8,775 incident
cases of cancer in AMB (excluding non-melanoma skin cancer);
(57.2%) occurred in women, (84.2%) were verified by microscopy
(cytology, hematology or pathology), (7.6%) were detected only
by death certificate, and (7.2%) by clinical history (Table 1). The
percentage of cases identified by microscopy was higher in women
than in men (88.0 and 81.4 respectively p <0.0001); in contrast,
the percentage of cases identified by death certificate was higher in
men than in women (9.1 and 6.5 p <0.0001).
The average age at diagnosis was 57.3 years in women and 61.8
years in men (p  <0.0001). The location of the most frequent
malignant tumors in women were breast (26.1%), colorectal
(9.1%), thyroid (9.1%), cervix (8.3%) and stomach (6.9%). In men,
the most frequent cancers were: prostate (26.1%), stomach (11.4%),
colorectal (9.4%), trachea bronchi and lung (6.7%), lymphoma and
myeloma (6.2%) (Table 2).
Rates are expressed per 100,000 persons-years. The cancer
incidence rate standardized by age (ASR) was 151.7 in men, and
157.2 in women. The standardized rates of the five most frequent
cancers in men were prostate (40.9), stomach (17.1), colorectal
(14.3), lung (10.3) and lymphoma (9.1). In women, they were
breast (41.2), thyroid (14.5), colorectal (13.7), cervix (13.0) and
stomach (10.2).
In women, the five tumor sites with a percentage of microscopic
diagnosis greater than 95.2% were: thyroid, lymphoma, leukemia,
kidney and breast. In men, they were skin melanoma, leukemia,
lymphoma, bladder and thyroid. The type of cancer with the
highest percentage of diagnosis by death certificate was: liver
(31.9% in women and 35.6% in men), pancreas (31.1% in women
and 33.3% in men) and lung (23.5% in women and 21.9% in men).
The behavior of the age-specific incidence of the two most frequent
types of cancer in women is different. Breast cancer rises sharply
since the end of the third decade of life, reaching its peak at around
70 years of age; in contrast, the incidence of thyroid cancer begins
in the middle of the second decade of life, and reaches its peak at
75
around 55 years of age, with a magnitude 60% lower than that of
breast cancer at this age (Fig. 1). In men, the incidence of gastric
cancer increases after 30 years of age, and that of the prostate
increases after 40 years of age, but the latter presents a much steeper
upward curve, almost tripling the incidence of gastric cancer at 80
years of age (Fig. 2).
During the 2008-2012 quinquennium, of 24,860 deaths registered in
AMB, 4,998 (20.1%) corresponded to malignant neoplasms; 50.2%
occurred in women. For the general population, the mortality rate
ardized by cancer was 84.6 per 100,000 persons-years. The most
frequent cancers were: stomach (13.9%), lung (11.4%), colorectal
(9.0%), breast (7.1%), prostate (6.0%), leukemia (5.3%), liver
(5.1%), lymphoma (5%), cervix (3.8%) and pancreas (3.5%).
Women had a standardized mortality rate by age of 78.0 per
100,000 women-year. The cancers that caused the greatest number
of deaths were breast (13.3%), stomach (11.8%), colorectal (9.4%),
lung (8.7%), cervix (7.1%), liver (4.8%), leukemia and lymphomas.
(4.7% each). In men, the mortality rate standardized by age was
94.8 per 100,000 men-year, cancers of stomach (15.9%), lung
(14.1%) and prostate (12.4%), colorectal (8.0%), liver (5.4%),
leukemia (6.0%) and lymphoma (5.4%) (Table 3 ).
Discussion
This study presents the results of cancer incidence and mortality in
the quinquennium 2008-2012, thus providing continuity with the
data for the 2003-2007 quinquennium25. In general, the quality of
the data analyzed was better than for the previous quinquennium,
because the percentage of cases that were detected only by death
certificate decreased.
In the interpretation of data, it is important to bear in mind that the
classification of the cases used in the current study was based on the
first revision of the ICD-O-3, which includes changes in the codes
related to the behavior of some tumor lesions and morphological
codes of hematolymphoid and central nervous system neoplasms,
which were not taken into account in the analysis of the previous
quinquennium.
When compared with the 2003-2007 quinquennium, the average
age at diagnosis moment was similar for both sexes. The total
number of new cases (excluding non-melanoma skin cancer)
increased 6.7%, as well as the percentage representation of women,
which went from 54.3% to 57.2%. However, the overall incidence
rate in men and women decreased, especially in men, because the
male/female ratio (m/f) was 1.0, showing a behavior contrary to
that reported by the Population Registry of Cali Cancer (RPCC,
for its initials in Spanish) for the same period (ratio m/f of 1.1)26,
but similar to the behavior reported for previous years in countries
such as Ecuador, Peru and Mexico27.
The standardized rates of incidence in the 2008-2012 period in AMB
were lower than those reported by RPCC in the same period26, as
well as those of the South American population (206.7 per 100,000
men-year and 180.6 per 100,000 women-year)27  and worldwide
(182.0 per 100,000 men-year and 165.2 per 100,000 women-year) 26.
Breast cancer was the most frequent in women from AMB, with
percentage representation and standardized incidence rate similar
 Uribe Pérez CJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)

Table 1. Quality index by cancer location and sex. Metropolitan Area of ​​Bucaramanga, 2008-2012.
Men Women
Place CIE-10
n % DCO % MV n % DCO % MV
Oral cavity and pharynx 116 5.2 91.4 69 1.4 88.4 C00-C14
Esophagus 43 16.3 79.1 29 20.7 72.4 C15
Stomach 427 6.6 89.5 345 11.3 82.6 C16
Colorectal 353 5.9 91.0 457 4.8 92.3 C18-C21
Liver 90 35.6 46.7 69 31.9 44.9 C22
Pancreas 54 33.3 37.0 61 31.1 37.7 C25
Lung 251 21.9 66.1 200 23.5 64.0 C33-C34
Melanoma, skin 59 0.0 100.0 53 3.8 92.5 C43
Breast 12 8.3 83.3 1,309 1.4 95.3 C50
Cervix 0 - - 418 3.8 91.6 C53
Others in uterus 0 - - 222 4.1 94.1 C54-C55
Ovary 0 - - 215 8.4 85.1 C56
Prostate 980 7.3 76.8 0 - - C61
Urinary Bladder 83 3.6 95.2 39 5.1 87.2 C67
Thyroid 66 0.0 93.9 456 1.5 97.4 C73
Lymphoma 231 1.3 96.1 225 0.9 97.3 C81-C90;C96
Leukemia 180 1.7 96.1 151 2.6 96.7 C91-C95
Others 795 12.7 75.0 672 15.5 70.9
All locations without skin 3,754 9.1 88.0 5,021 6.5 81.4
DCO: death certificate as the only evidence
VM: microscopic verification

Table 2. Cases and crude and standardized incidence rates per 100,000 persons-year due to cancer and sex. Metropolitan Area
of Bucaramanga, 2008-2012
Both Men Women
Place CIE-10
n % CR ASR n % CR ASR n % CR ASR
Oral cavity and Pharynx 185 2.1 3.4 4.3 116 3.1 4.5 4.6 69 1.4 2.4 2.1 C00-C14
Esophagus 72 0.8 1.3 1.2 43 1.1 1.7 1.7 29 0.6 1.0 0.8 C15
Stomach 772 8.8 14.3 13.1 427 11.4 16.5 17.1 345 6.9 12.3 10.2 C16
Colorectal 810 9.2 15 13.9 353 9.4 13.6 14.3 457 9.1 16.3 13.7 C18-C20
Liver 159 1.8 2.9 2.7 90 2.4 3.5 3.7 69 1.4 2.4 2.0 C22
Pancreas 115 1.3 2.1 2.0 54 1.4 2.1 2.2 61 1.2 2.2 1.8 C25
Lung 451 5.1 8.4 7.8 251 6.7 9.7 10.3 200 4.0 7.2 5.9 C33-C34
Melanoma, skin 112 1.3 2.1 2.0 59 1.6 2.3 2.3 53 1.1 1.9 1.7 C43
Breast 1.321 15.1 24.3 23.0 12 0.3 0.5 0.5 1.309 26.1 46.3 41.2 C50
Cervix 418 4.8 7.8 7.1 0 0.0 0.0 0.0 418 8.3 15.0 13.0 C53
Others in uterus 222 2.5 4.1 3.9 0 0.0 0.0 0.0 222 4.4 7.8 7.1 C54-C55
Ovary 215 2.5 4.0 3.8 0 0.0 0.0 0.5 215 4.3 7.7 7.0 C56
Prostate 980 11.2 18.1 17.3 980 26.1 37.7 40.9 0 0.0 0.0 0.0 C61
Urinary Bladder 122 1.4 2.3 2.0 83 2.2 3.2 3.3 39 0.8 1.4 1.1 C67
Thyroid 522 5.9 9.7 8.9 66 1.8 2.5 2.4 456 9.1 16.3 14.5 C73
Lymphoma 456 5.2 8.4 8.1 231 6.2 8.9 9.1 225 4.5 8.0 7.3 C81-C90;C96
Leukemia 331 3.8 6.1 6.3 180 4.8 6.9 7.3 151 3.0 5.4 5.5 C91-C95
Other neoplasms 1.467 16.7 27.1 25.9 795 21.2 30.5 31.6 672 13.4 23.9 21.3
Total Cases without C44 8.775 100 162.2 153.1 3.754 100.0 144.5 151.7 5.021 100.0 178.7 157.2
CR: Crude rates per 100,000
ASR: Standardized rates by age per 100,000

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Tabla 3. Casos y tasas de mortalidad crudas y estandarizadas (población mundial Segi) por 100.000 personas-año, por localización y
sexo. Área Metropolitana de Bucaramanga, 2008-2012
Both Men Women
Place CIE-10
n % CR ASR n % CR ASR n % CR ASR
Oral cavity and Pharynx 112 2.2 2.1 1.9 81 3.4 3.1 3.3 31 1.2 1.1 0.9 C00-C14
Esophagus 94 1.9 1.7 1.5 60 2.5 2.3 2.3 34 1.3 1.2 1.0 C15
Stomach 686 13.7 12.8 11.6 379 15.9 14.7 15.2 307 11.8 11 9.0 C16
Colorectal 455 9.0 8.3 7.4 204 8.0 7.9 8.1 241 9.4 8.6 6.7 C18-C20
Liver 254 5.1 4.7 4.4 130 5.4 5.0 5.3 124 4.8 4.4 3.7 C22
Pancreas 175 3.5 3.3 2.9 80 3.3 3.1 3.2 95 3.6 3.4 2.7 C25
Lung 563 11.3 10.5 9.6 337 14.1 13.0 13.7 226 8.7 8.1 6.6 C33-C34
Melanoma, skin 50 1.0 0.9 0.8 26 1.1 1.0 1.0 24 0.9 0.8 0.7 C43
Breast 349 7.0 6.5 6.1 3 0.1 0.1 0.1 346 13.3 12.4 10.8 C50
Cervix 186 3.7 3.5 3.1 186 7.1 6.7 5.7 C53
Others in uterus 55 1.1 1.0 0.9 55 2.1 2.0 1.6 C54-C55
Ovary 128 2.6 2.4 2.2 128 4.9 4.6 4.0 C56
Prostate 297 5.9 5.5 4.6 297 12.4 11.5 11.3 C61
Urinary Bladder 63 1.3 1.2 1.0 36 1.5 1.4 1.4 27 1.0 1.0 0.7 C67
Lymphoma 251 5.0 4.7 4.3 129 5.4 5.0 5.1 122 4.7 4.4 3.7 C81-C90;C96
Leukemia 266 5.3 4.9 4.7 143 6.0 5.5 5.6 123 4.7 4.4 4.1 C91-C95
Other locations 1.013 20.3 18.8 17.3 480 20.1 18.5 19.1 533 20.4 19.1 16.0
Total cases of cancer 4,997 100.0 92.9 84.6 2,390 100.0 92.4 94.8 2,607 100.0 93.3 78.0

CR: Crude rates per 100,000

ASR: Standardized rates by age per 100,000

to those of the previous quinquennium (41.2 vs 41.9 per 100,000
women-year)25, and the global behavior reported for the year
201226. However, the order of the other more frequent cancers
in women from AMB was modified, placing thyroid cancer in
the second place, followed by colorectal cancer, and displacing
cervix cancer to the fourth place; cervix cancer had occupied the
second place in the previous quinquennium, showing a sustained
tendency to decrease in its rate since 2000. Stomach cancer was
the fifth cancer in frequency, with the same incidence as in the
previous quinquennium.
Women
600
Specific rates per age ( 100,000 people - year)
According to the estimates of the National Health Observatory (ONS,
for its initials in Spanish) in Colombia for the year 2012, breast cancer,
followed by cervical cancer, continued to have the highest incidence
in women, with magnitudes higher than those of AMB (47.3 and 16.3
per 100,000 women-year, respectively); while cancer of the colon,
rectum and anus (7.8 per 100,000 women-year), thyroid cancer
(11.2 per 100,000 women-year) and stomach cancer (9.6 per 100,000
women-year) had lower rates. Particularly, the latter showed a marked
downward trend in the country during the 2010-2014 period28, in
contrast to the stability of its behavior in women from AMB.
Men
600
Specific rates per age ( 100,000 people - year)

400
400

200
200

0
0 20 40 60 >=80 0
0 20 40 60 >=80
Age (years)
Age (years)
Thyroid Breast Stomach Prostate

Figure 1. Age-specific incidence rates of the most frequent Figure 2. Age-specific incidence rates of the most frequent cancers
cancers in women in the metropolitan area of Bucaramanga, in men in the metropolitan area of Bucaramanga, stratified by
stratified by quinquennial 2008-2012. quinquennial 2008-2012.

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 Uribe Pérez CJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
In men, the order of the five cancers with the highest incidence
remains the same from one quinquennium to another; all but
colorectal cancer showed a decrease in the standardized incidence
rate compared to the quinquennium 2003-200725. These five types
of cancer were also the ones with the highest incidence for men
in the country in 2012, although with standardized rates higher
than those of AMB and with an increasing tendency in the
quinquennium 2010-2014; with the exception of stomach cancer,
which showed a clear tendency to decrease at national level28.
In relation to mortality, the profile of AMB is similar to the
quinquennium 2003-2007, although with lower rates in most
locations; especially stomach cancer, which decreased particularly
in men, from 20.1 to 15.2 per 100,000 men-year. In contrast,
the death rate for colorectal cancer increased in men, as did the
mortality rate from leukemia, which increased in men and women,
with mortality in the period 2008-2012 being 2.4 times higher than
in the previous quinquennium25.
The outlook in AMB contrasts with that of the country, which
according to ONS calculations had higher standardized mortality
rates and a tendency to increase in several locations. However,
mortality from leukemia showed an opposite behavior compared
to the national estimate for 2012, with AMB reaching a 46.5%
higher rate in men and 70.5% higher in women in the 2008-
2012 quinquennium. Unlike the behavior of the country, whose
mortality from cancer of the colon, rectum and anus increased in
men and women during the quinquennium 2010-2014, in AMB
this behavior was only observed in men28.
The behavior of the country reflects the double burden of cancer
faced by the Central and South America regions, which manifests
in high rates of cancer related to infection (cervix, stomach and
liver) and an increase in cancers related to lifestyle (prostate, breast,
colon and rectum), the latter ones possibly have to do with aspects
of economic development, such as the increase in the age of first
pregnancy, lower parity, smoking and alcohol consumption, diets
poor in fruits and vegetables, obesity and physical inactivity27.
Although in several locations of tumors, AMB has lower incidences
compared to the total population of the country, here the double
burden is also appreciated. In addition, the magnitude of colorectal
cancer and its tendency to increase in both sexes is noteworthy, as
well as the high frequency of stomach cancer and the increased
incidence of thyroid cancer in women. Also, although the risk of
dying from cancer is lower in AMB than in the rest of the country
for almost all locations, and it was lower than in the previous
quinquennium, the increase in mortality from colon cancer and
rectum in men, and from leukemia for both sexes is significant.
This profile raises more attention to the prevention of colon and
rectum cancer in AMB, where the magnitude of the incidence is
similar for both sexes, unlike what happens in much of the world.
This type of cancer shares with breast cancer several prevention
measures, such as the maintenance of body weight, increased
physical activity and decreased consumption of alcohol, red and
processed meats, and tobacco1.
It should be noted that the prevalence of overweight or obesity
in the province of Santander is 50.1%, higher in men, although
abdominal obesity is higher in women (46.6% versus 40.11%), the
78
consumption of fruits and vegetables is very low (94.9% did not
reach the recommended daily consumption)29, and gender and
socioeconomic inequalities have been documented in the practice
of physical activity, with women being less active, especially
those engaged in unpaid work30. Inequalities in lifestyles demand
comprehensive approaches that deepen the role of social structures
in the configuration of health decisions and practices, as these do
not depend solely on personal decisions31,32.
Improving and promoting equity at all preventive levels in relation
to stomach cancer is also a priority for AMB, especially when
marked socio-economic inequalities have been documented in the
survival of patients, despite the existence of the “universal” system
of social security in health33.
With regard to thyroid cancer, this presents an increase on
incidence rates similar to the data reported for several regions of
the world and the country. In some countries such as the United
States, the increase in incidence rates was recorded three decades
ago due to a greater use of diagnostic methods such as ultrasound,
which allowed them to find very small nodules that would
probably go unnoticed for a long time; that is, the relative increase
in incidence could be influenced by the diagnosis.
Finally, the behavior of hematolymphoid neoplasms, especially in
leukemia, with mortality rates that have doubled the rates of the
previous quinquennium in our region, raises concerns about the
factors that have impacted this marked increase in mortality rates.
It is important to explore modifiable factors, especially those that
have been associated with barriers in the health care of patients
with cancer, such as administrative, economic and cultural factors,
with delays in the opportunity for diagnosis and treatment34.
Conclusions
This study presents the magnitude of cancer in the Metropolitan
Area of ​​Bucaramanga during the quinquennium 2008-2012,
comparatively with the quinquennium 2003-2007. Positive
behaviors are revealed for several cancers, which show a decrease
in the incidence of one quinquennium to another, or magnitudes
lower than those of the country; however, the magnitude and
tendency to increase in colorectal cancer for both sexes is to
significant, as well as the high frequency of stomach cancer, and
the increased incidence of thyroid cancer in women. Likewise,
mortality from colon and rectal cancer in men, and from leukemia
for both sexes has increased, which requires further investigation
and the strengthening of preventive measures.
Conflicts of interest:
The authors declare that they have no conflicts of interest. Interests
or values ​​different from the usual ones in an investigation have not
influenced the elaboration of this manuscript
Acknowledgements:
The Population Registry of Cancer of the Metropolitan Area of​​
Bucaramanga deeply thanks all the health institutions, the medical,
paramedical and administrative staff for their cooperation and
the support provided. The Population Registry of Cancer of the
Metropolitan Area of ​​Bucaramanga (RPC-AMB) is a research
project of the Universidad Autónoma de Bucaramanga, UNAB,
funded by UNAB and the INC.
 Uribe Pérez CJ/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
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 Brome BMR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original Article

Cancer incidence and mortality in Medellin-Colombia, 2010-2014

Incidencia y mortalidad por cáncer en Medellín, Colombia. 2010-2014

Mary Ruth Brome Bohórquez, Diego Mauricio Montoya Restrepo, Liseth Amell Salcedo

Registro Poblacional de Cáncer de Antioquia. Secretaría Seccional de Salud y Protección Social de Antioquia. MEdellin, Colombia

Brome BMR, Montoya RDM, Salcedo LA. Cancer incidence and mortality in Medellin, Colombia. 2010-20. Colomb Med (Cali). 2018; 49(1): 81-88. doi: 10.25100/cm.v49i1.3740

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 24 January 2018
Revised: 13 February 2018
Accepted: 6 April 2018
Keywords:
Incidence, mortality, cancer,
Colombia.
Palabras clave:
Incidencia, mortalidad,
cáncer, Colombia.
Background: This study provides information on cancer incidence
and mortality in a Colombian population during 2010-2014, based on
the data and methodology of the Population-based Cancer Registry of
Antioquia to facilitate the implementation of cancer control strategies.
Methods: This is a descriptive study of cancer incidence and mortality
in a population, residing in the urban area of the municipality of Medel-
lin. The cancers included in the study are those prioritized in the cancer
control plan for Colombia (PDCC-cancers). The collection, processing
and systematization of the data were performed in accordance with in-
ternationally standardized parameters for population cancer registries.
Incidence and mortality rates were calculated by gender, age and tumor
location.
Results: During 2010-2014 there were 22,379 new cancer cases record-
ed in the urban area of the municipality of Medellin, of which 43.5%
corresponded to the PDCC-cancers. During the same period, 14,922
cancer deaths were reported, 23.5% related to the PDCC-cancers, 53.5%
in women. Prostate cancer and breast cancer were the principal cause
of morbidity in men and women, respectively, and lung cancer was the
principal cause of death for both sexes.
Conclusion: Cancer is a health problem for the population of Medel-
lin. It is necessary to emphasize research and monitor risk factors, the
health response and the capacity of the health provider network when
facing the growing demand caused by this epidemic.
Antecedentes: Este estudio proporciona información sobre la
incidencia y mortalidad por cáncer en una población colombiana
durante 2010-2014, a partir de los datos y la metodología del Registro
Poblacional de Cáncer de Antioquia para facilitar la implementación de
estrategias para el control del cáncer.
Métodos: Este estudio es un estudio descriptivo, cuya población objeto
reside en el área urbana del municipio de Medellín. Se incluyeron para
el análisis los cánceres priorizados por el plan de control de cáncer de
Colombia (cánceres-PDCC). La recolección, el procesamiento y la
sistematización de los datos se realizaron de acuerdo con los parámetros
estandarizados internacionalmente para los registros poblacionales de
cáncer. Las tasas de incidencia y mortalidad se calcularon por sexo, edad
y ubicación del tumor.
Resultados: En el periodo 2010-2014 se registraron 22.379 casos
nuevos de cáncer en el área urbana del municipio de Medellín, de ellos,
43.5% corresponde a los cánceres-PDCC. Para el mismo periodo se
reportaron 14,922 muertes por cáncer, 23.5% pertenecen a cánceres-
PDCC, 53.5 %, ocurrieron en mujeres. El cáncer de próstata y el cáncer
de mama fueron la primera causa de morbilidad por cáncer en hombres
y mujeres respectivamente, y el cáncer de pulmón fue la principal causa
de muerte por cáncer para los dos sexos.
Conclusión: El cáncer es un problema de salud para la población del
municipio de Medellín. Se requiere hacer énfasis en las investigaciones
y monitoreo de los factores de riesgo, así como hacer seguimiento a la
respuesta sanitaria y la capacidad de la red de prestadores frente a la
demanda creciente de esta epidemia.

Corresponding author:
Mary Ruth Brome Bohórquez. Calle 42 B 52-106. Piso 8. Oficina 801.
Teléfono: 383 54 01. e-mail: institucional: mary.brome@antioquia.gov.co

81
 Brome Bohórquez MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
Introduction
Cancer is one of the principal causes of morbidity and mortality
around the world; in 2015 there were 8.8 million deaths. It
is estimated that the number of new cases will increase by
approximately 70% in the next 20 years1,2. In Colombia from 2007
to 2011 there were an estimated 29,734 new cancer cases (men)
and 33,084 (women) per year. The age standardized incidence rate
(ASIR) for every cancer, except skin, per 100,000 inhabitants was
151.5 in men and 145.6 in women3.
In response, the Ministry of Health and Social Protection and the
National Cancer Institute (or INC) implemented the  Model for
Cancer Control in Colombia  in 2006. This model defines cancer
control as a series of activities that seek to decrease the burden of the
illness in Colombia. In order to execute the plan, a description of the
epidemiological situation and an evaluation of the determinant factors
is fundamental, which allows the health system to orient oncological
service and ensure an adequate social response4. The Decade Cancer
Control Plan (or PDCC)5 focuses its actions on the control of breast,
cervix, prostate and colorectal cancer as well as acute pediatric
leukemia. These tumors, in addition to stomach cancer, correspond to
31.7% of cancer mortality in Colombia during 2007-20113.
Since 2000 the mission of the Population-based Cancer Registry of
Antioquia (or RPC-A) is to offer reliable and high-quality cancer
data in the state of Antioquia and facilitate the implementation of
prevention and diagnostic programs and integral cancer care to
diminish the burden of this disease in the region. Currently, the
RPC-A is part of the International Association of Cancer Registries
(or IACR) and the Network of Population-based Cancer Registries
of Colombia, alongside the RPC of Cali, Bucaramanga, Pasto,
Manizales and Barranquilla.
The present study aims to describe the cancer incidence and
mortality in Medellin during 2010-2014, as both a contribution
from the RPC-A to understand better the epidemiological behavior
of cancer in the state of Antioquia and to come closer toward
achieving the objectives outlined in the PDCC.
Materials and Methods
Medellin is the second most populated city in Colombia, capital
of the state of Antioquia. The city is situated in the middle of the
Central Mountain range of the Andes, 1,538 meters above sea
level. The weather is warm with little variation in temperature
throughout the year. The Medellin River runs through the entire
length of the city. It is the nucleus of the metropolitan area in the
Aburra Valley. The other neighboring municipalities from north
to south are Barbosa, Girardota, Copacabana, Bello, Envigado,
Itagüí, Sabaneta, La Estrella and Caldas. Industry represents 43.6%
of the internal product. The industrial sectors in order of economic
participation are the textile industry (20%), chemical products
and substances (14.5%), beverages (11.0%) and food (10.0%).
The remaining 10.0% include sectors such as metal mechanics,
electrical and electronic industries, among others6.
Population
The inhabitants descend from a mixture of European, Indigenous
and African origin, with a clear preponderance of the first.
82
Males 80-+ Females
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
10 8 6 4 2 0 0 2 4 6 8 10
Percentage
Figure 1. Medellin, Colombia. Population pyramid, 2013. Source: Based on projections from
the National Administrative Department of Statistics. DANE, Colombia, 2013.
According to estimates from the National Administrative
Department of Statistics in Colombia (or DANE), in 2013 there
were 2,386,233 inhabitants in the urban area and 31,092 in the
rural area, in total 52.9% of the population were women (Fig. 1).
The Aging Index jumped from 8 senior citizens per 100 minors
below the age of 15 in 1964 to 51 seniors in 2013; life expectancy
increased from 60 years in the mid-20th century to 77.5 years in
2013, 75.5 years for men and 78.7 years for women7.
Registry area
The state capitol of Medellin is comprised of 105 km2 of urban area
and 270 km2 of rural area.
Case definition
For this study the RPC-A acts as a selective population registry. It
included all of the malignant, invasive tumors diagnosed for the
first time in the five year span between 2010-2014 (incidence) by the
locations prioritized in the strategic lines of the PDCC in Colombia
2012-2020: breast (in women), cervical, prostate, colorectal and
acute pediatric leukemia, in addition to stomach cancer. The basis
of diagnosis could be histological, clinical, bone marrow cytology
or death certificate. The statistical analyses only included primary
malignant tumors or multiple invasive. In the analysis pre-invasive
cervical neoplasms will be taken into account. Benign tumors and
those of uncertain behavior were excluded. The cases of patients that
arrived to the city for diagnosis and treatment were not considered
residents of Medellin. The incidence date corresponds to the first
chronological event of diagnosis, confirming the sickness.
The information was collected by different means (active and
passive), continuous and systematic recollection in the health
institutes that produce cancer data: hospitals, clinics, oncology
units, pathology and hematology laboratories, medical centers,
specialized practices, the DANE and the State Secretary of Health
and organisms in charge of processing death certificates, which
provide the base to tabulate official mortality. The data collected
were correlated to the patient’s socio-demographic variables,
tumor clinic and follow up. The information was then processed
according to the confidentiality criteria stipulated by the IACR for
population-based cancer registries8,9.
 Brome Bohórquez MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)

The cases were entered into the system designed by the RPC-A
to eliminate duplicates, process and complement the data. The
identification of multiple primary tumors follows the norms
established by the IACR10. Tumor topography (localization) and
morphology (histology) were codified with the International
Classification of Diseases for Oncology Third Edition (or
CIE-O-3)11. In order to compare the data, some localizations were
grouped together.
To ensure quality the RPC-A employs a set of indicators,
exhaustiveness indicators (percentage of incident cases identified
by death certificate and cause of death/incidence) and validity
indicators (distribution of cases according to the most valid base
for a cancer diagnosis and percentage of microscopically verified
cases).
Results
From 2010 to 2014, 56,650 new cancer cases were registered in the
RPC-A, (60.1% in women); and 30,465 cancer deaths were certified
in the state of Antioquia (48.4% in men). Forty-five percent of the
cases and 48.9% of cancer deaths occurred to permanent residents
in the municipality of Medellin.
Of the 22,379 new cancer cases diagnosed in Medellin, 61.6%
were women. The average age for cancer diagnosis was 63 for men
and 55 for women. The specific rates, crude rates (CR) and age
standardized rates (ASR) with the world population are expressed
per 100,000 people-year (p-y). For men the cancer incident rate per
100,000 people per year (p-y) for all localizations was 171.3 (CR)
and 144.4 (ASR). In women the CR was 202.9 and the ASR 145.6.

The rates of incidence and mortality are calculated conventionally,
utilizing the mid-year population estimates and projections
denominator calculated by the official 2005 Census12.  Cases
without age (0.5% 111/22,379) and in situ tumors were excluded
from the study. In the case of cervical cancer, the incidence rates
for invasive and pre-invasive neoplasms were calculated separately.
The age adjusted rates were estimated by direct methods with
the world population standard (or SEGI), the specific rates were
calculated by variable: gender, localization and five-year age ranges
(18 categories). The incidence and mortality results are presented
for the 2010-2014 time period in their corresponding tables and
graphs.
Among men the five principle cancer localizations were prostate
(26.9%), colorectal (7.8%), stomach (7.3%), lung (6.1%) and bladder
(6.1%). Among women the most frequent localizations were: breast
(25.8%), thyroid (13.6%), colorectal (7%), cervix (5.5%) and lung
(4.4%). In all, these localizations represented 54.7% of all the new
cancer cases diagnosed during the five-year period.
Of the 14,922 cancer-related death certificates issued in Medellin,
53.4% were for women. The average age at the moment of death
was 68 for men and 67.2 for women. Among men the cancer
mortality rates per 100,000 p-y for all localizations was 123.3 (CR)
and 101.1 (ASR). Among women the CR was 126.0 and the ASR

Table 1. Municipality of Medellin, Colombia. Incidence and mortality data for malignant tumors prioritized by the Decade Cancer
Control Plan in Colombia, quality indicators (exhaustiveness and validity) distributed by sex and localization during 2010-2014. Incident
quality indicators.
Incidence Mortality
Localization Age Rate M:I VM% DCO% Rates
n % n %
Desc CR ASR CR ASR
Breast (C50) 3,286 25.7 14 51.9 36.5 0.33 97.4 0.1 1,075 13.5 17.0 12.9
Cervix (C53) 708 5.5 1 11.2 8.5 0.55 98.0 0.1 391 4.9 6.2 4.9
Prostate (C61) 2,571 26.8 15 45.7 38.6 0.31 99.3 0.2 798 11.5 14.2 14.6
Colorectal (C18-C20) 1,640 7.3 5 13.7 10.0 0.74 98.5 0.2 1,216 8.1 10.2 7.2
Men 747 7.8 3 13.3 11.0 0.77 98.4 0.0 575 8.3 10.2 8.4
Women 893 7.0 2 14.1 9.4 0.72 98.6 0.3 641 8.0 10.1 6.5
Colon (C18) 1,080 4.8 3 9.0 6.6 0.94 98.6 0.2 1,015 6.8 8.5 6.0
Men 474 4.9 3 8.5 7.0 1.00 98.5 0.0 476 6.9 8.5 6.9
Women 606 4.7 0 9.6 6.4 0.89 98.7 0.3 539 6.8 8.5 5.4
Rectum (C19-C20) 560 2.5 2 4.7 3.4 0.36 98.8 0.2 201 1.3 1.7 1.2
Men 273 2.8 0 4.8 4.0 0.36 98.8 0.0 99 1.4 1.8 1.5
Women 287 2.2 2 4.6 3.0 0.36 99.3 0.3 102 1.3 1.6 1.1
Stomach (C16) 1,209 5.4 12 10.2 10.1 1.21 98.3 0.4 1,467 9.8 12.3 10.3
Men 695 7.2 6 12.4 12.3 1.15 98.4 0.3 801 11.5 14.2 13.6
Women 514 4.0 6 8.2 8.1 1.30 98.1 0.6 666 8.3 10.5 8.0
All localizations‡ 22,379 111 187.1 143.4 0.67 96.3 0.2 14,922 124.7 89.7
Men 9,602 42.9 43 171.3 144.4 0.72 97.4 0.2 6,941 123.3 101.1
Women 12,777 57.1 68 202.9 145.6 0.62 95.5 0.2 7,980 126.0 82.6
Infantile Leukemia 77 0 0.6 1.1 0.60 98.7 1.3 46 0.4 0.6
Men 38 0 0.7 1.0 0.55 98.8 1.2 21 0.4 0.5
Women 39 0 0.6 1.1 0.64 98.6 1.4 25 0.4 0.7
Source: Population-based Cancer Registry of Antioquia. Vital Statistics SSSA - DANE.
n: number of cases;
M:I: Reason Mortality-Incidence;
VM%: Verified Microscopically (histology/hematology);
DCO%: Death Certificate Only.
The specific, crude (CR) and age standardized rates (ASR) with the world population are expressed per 100,000 p-y.
‡ All localizations, except C44 (Skin non melanoma)

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Incidence Cervix Colon cancer Stomach cancer
150 150
400
100

300 80

Rate per 100,000 people - year

Rate per 100,000 people - year
100 100

Rate per 100,000 people - year

Rate per 100,000 people - year

60
200

40
50 50
100

20

0
25 35 45 55 65 75
0 0 0
10 20 30 40 50 60 70 80 30 40 50 60 70 80 30 40 50 60 70 80
Age (year) Age (year) Age (year)
Prostate Breast Colon
Stomach Cervix Cancer Pre-invasive neoplasm Men Women Men Women

Figure 2. Medellin, Colombia, 2010-2014. Age and Sex specific incidence rates (per 100,000 p-y) for the 9,538 cancers prioritized in the PDCC in Colombia. Source: Population-based Cancer
Registry of Antioquia. A. The age specific incidence rates were higher for prostate cancer and lower for cervical cancer. The incidence of precursor lesions of cervical cancer peaked at approximately
40 years of age. B. The morbidity of gastric cancer was greater for men older than 45 years old, the difference was less apparent for colorectal cancer with a slightly higher rate in women below 50
years of age.

was 82.6. The age specific cancer incidence and mortality rates groups, half of the cases were diagnosed before 50 and only 4.3%
were higher in women below 55 years of age, while for men it was over 80 (Fig 2).
after 55 (Supplementary Tables 1S and ​2S).
Pre-invasive Cervical Neoplasms: The peak incidence rate for
Lung cancer (19%) was the first cause of death among men, followed pre-invasive cervical lesions occurred between 35 and 39 years old,
by stomach cancer (11.5%), prostate (11.5%), colorectal (8.3%) and 60.8% were diagnosed before 40.
liver (6.2%). Lung cancer was the principle cause of death among
women (15.1%), followed by breast cancer (13.5%), stomach (8.3%), Prostate cancer: The average age of diagnosis was 68, 65 for
colorectal (8.0%) and leukemia/lymphomas (7.6%). In all, these five colorectal cancer, 65 for stomach cancer and 7 for acute pediatric
principle causes constitute 52.5% of all cancer deaths that occurred leukemia (Fig 2).
in Medellin during the five-year interval from 2010 to 2014.

Cancers prioritized in the Decade Cancer Control Plan in Mortality by PDCC malignant tumors in Medellin
Colombia, 2012 - 2021. During 2010-2014, the PDCC-cancers represented 33.5% (4,993)
Of the total new cancer diagnoses in residents of Medellin, 9,538 of the total cancer deaths in Medellin (14,922); 2,798 (56.0%) of the
(42.6%) corresponded to stomach, prostate, breast, cervical, deaths occurred in women and 2,195 (44.0%) in men.
colorectal cancer and acute pediatric leukemia, that altogether will
be denominated for the analysis as PDCC-cancers; 4,075 (42.7%) The crude and standardized mortality rate (CMR and ASMR) by
cases were diagnosed in men and 5,463 (57.3%) in women. age for the PDCC-cancers was 38.9 and 31.6 in men and 44.2 and
29.7 in women.
For the PDCC-cancer group the CR and the ASR per 100,000 p-y
was 72.3 and 60.9 in men and 86.3 and 61.3 in women. The average age at the moment of death was 64 for breast cancer,
58 for cervical cancer, 78 for prostate cancer, 68 for colorectal and
During the 2010-2014 period there were 2,254 women with pre- stomach cancer. In the case of acute pediatric leukemia, the average
invasive cervical lesions, in 44 cases the age was unknown, CR was age of death was 9.
35.6 and the ASR 30.5.
Figure 3 describes the curves for age specific mortality rates. The
Quality criteria for incidence data mortality rate for breast cancer is higher for women below 65 years
Table 1 shows the quality indicators for the incidence information old. For older adult older than 65 years of age deaths are caused by
during 2010-2014 period for malignant tumors prioritized in prostate and stomach cancer. This is the reason why (M:I) is greater
the PDCC. The percentage of diagnosed cases with microscopic than 1 in women with cervical cancer and in men with prostate
verification (histology of primary tumor, cytology and bone marrow cancer over 70.
aspiration) for men and women was 99.8%; in this tumor group the
percentage of registered cases that only had a death certificate as its The specific mortality rates below 70 are higher in women with
only evidence was 0.2%. The global cause of mortality: incidence breast cancer. After 70 this is the reason why (M:I) is greater than 1
was 0.67 for the total population, 0.72 for men and 0.62 for women. in men with prostate cancer and women with cervical cancer

Breast Cancer: The average age of diagnosis was 58 years old, Discussion
42.5% in people below 50 years of age and only 12.5% over 80.
The Population-based Cancer Registry of Antioquia (or RPC-
Cervical Cancer: The specific incidence rates of invasive cervical Antioquia) compiled and classified all of the new cancer cases and
cancer reached a maximum value of 20 per 100,000 at approximately cancer-related deaths that occurred in Medellin, the second most
30 years of age and later leveled off and remained stable for all age populated city in Colombia. This article presents the incidence and
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 Brome Bohórquez MR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
Mortality Cervical cancer Breast cancer Prostate cancer
500 100 500 500

400 400 400

Rate per 100,000 people - year

Rate per 100,000 people - year

Rate per 100,000 people - year
Rate per 100,000 people - year

300
300 300

200
200 200

30
100
20 100 100

10
0
30 40 50 60 70 80 0 0 0
Age (year) 30 40 50 60 70 80 80 30 40 50 60 70 80 30 40 50 60 70 80
Age (year)
Age (year) Age (year)
Prostate Stomach Colorectal
Breast Cervix Incidence Motality Incidence Motality Incidence Motality

Figure 3. Medellin, Colombia, 2010-2014. Age and sex specific mortality rates (per 100,000 p-y). Source: Population-based Cancer Registry of Antioquia and Vital Statistics SSSA - DANE.

mortality rates for those cancers prioritized in the PDCC during with HER2 over-expression and higher rates of systemic relapse in
2010-2014. The PDCC-cancers were responsible for 42.4% of the any clinical stage in comparison with postmenopausal women21-23.
morbidity and 33.4% of the cancer-related mortality in Medellin.
This article is the product of a collaboration between the Secretary Prostate cancer was the first cause of morbidity and the second
of Health of Antioquia and the network of oncological service cause of cancer mortality in Medellin, 84.2% was concentrated
providers in the city. in the 60 to 80 age group. Prostate cancer affects older men more
frequently, which is an important health concern in developed
The information provided by the RPC-A indicates that cancer is a countries (Table 2S). In these countries 15% of cancers in men are
public health problem in Medellin. It was the second cause of death prostate cancer in contrast to 4% in developing countries24,25.
after circulatory system diseases and responsible for 25% of deaths that
occurred in the city13. During the 5-year period (2010-2014) cancer Malignant colorectal tumors in Medellin during 2010-2014
was diagnosed in 5,225 new cases and 2,963 deaths a year for residents affected more women than men. In both sexes, the cases increased
in the city of Medellin, according to the information provided by the after 55 years of age. Colombia can be classified as a country with
Sectional Secretary of Health and Social Protection of Antioquia. a low risk for colorectal cancer, but its incidence has increased,
coinciding with profound lifestyle changes. The majority of
The morbimortality risk for cancer in the region is determined by Colombians live in capital cities, few follow the recommendations
multiple factors. Cancer is part of a group of complex diseases of of exercising a minimum of 150 minutes a week and the prevalence
complex etiologies. Some factors are recognized, including genetic of overweightness is an increasing trend. This condition is more
factors and lifestyle choices, like smoking, diet and exercise; certain prevalent in women and in the 50 to 64 age group26,27.
types of infections and the exposition to some chemical substances
and radiation14. In Medellin, the majority of cancer determinants Gastric cancer is the principle cause of cancer mortality in
are yet to be identified. Colombia5, the risk is greater for men and the age specific rates
increase exponentially at 60 years of age (Table 2S and Figure 3).
Lung cancer is the primary cause of mortality in men and women The epidemiology of disease varies considerably by region and sex,
in Medellin during the five-year period. The prevalence of smoking due to the difference in eating habits, age and other risk factors
in the city reaches 25.5%, inversely proportional to the educational in the population28. In Colombia, gastric cancer has an annual
level and the proportion of smokers is greater in people that also incidence of 16.3/100,000 inhabitants and mortality is calculated
have a high consumption of alcohol. In Colombia, Medellin is at 14.2/100,000 inhabitants5. Five-year survival is less than 15%
recognized as the city with greatest level of air pollution, exceeding because patients are diagnosed at advanced stages29-31  The cause
the norms established by the WHO and posing as a risk to human M:I for gastric cancer was greater than 1, suggesting that incidence
health. Mortality from lung cancer is 2.4 times greater than in rates are underestimated (Table 1S).
Bogota and 1.7 times greater than the mortality in Colombia by
the same cause15,16. Table 2 shows the comparison of the ASIR for all cancer localizations
in Medellin with four other Colombian registries situated in Cali32,
Different Mexican studies indicate that 50% of women with breast Bucaramanga33, Manizales34 and Pasto35. The average annual ASR
cancer are younger than 50 years old at the time of diagnosis, in was 144 per 100,000 men and 145 per 100,000 women during 2010-
contrast to 22% to the Caucasian population17,18. In Medellin, the 2014. These findings are comparable to those observed in Pasto
data shows that during 2010-2014, 42.5% of the cases occurred (134 men and 146 women per 100,000), albeit lower than those in
in women younger than 50. This increased proportion of cases in Cali (205 men and 186 women); Bucaramanga (154 men and 157
young women is important because the diagnosis and behavior women) and Manizales (156 men and 165 women per 100,000). A
are generally more aggressive, with a disproportionately greater notable difference from other cancer registries is that Medellin has
number of years lost due to cancer19,20 This is a result of detection a high percentage of cases by microscopy, which suggests possibly
at advanced stages, a greater proportion of triple negative tumors considering a subregister.
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The comparison of the ASR of PDCC-cancers in Medellin, data Strengths

provided by the RPC-A, with the ASR reported by the RPC-Cali,
RPC-Bucaramanga, RPC-Manizales and RPC-Pasto shows that the
ASIR for breast and prostate cancer were similar to those reported
by RPC-Manizales and lower than other Colombian cities. For
stomach cancer the ASR in women showed little variation from 8.1
in Medellin and 11.9 in Pasto. In men there was greater contrast,
12.3 in Medellin to 26.5 in Pasto. In Medellin the incidence of
colon cancer is lower than those reported in other registries with
the exception of Pasto that reported the lowest ASR in both sexes
for this malignant tumor. It is noteworthy that the ASR for cervical
cancer in Medellin is lower than those reported by other registries
(Table 2).
In Medellin the incidence rate of cervical cancer is below the
national average and the mortality rates are very close to the
goals proposed in the PDCC for 2021: Reduce the mortality rate
of cervical cancer to 5.5 per 100,000 women. The work of the
Sectional Secretary of Health and Social Protection of Antioquia is
noteworthy, continuing the cervical cancer detection and control
Program that the National Cancerology Institute implemented in
Colombia during the 90s and later continued under the auspices of
the National Institute of Health in the quality control Program in
cervicouterine cytology. The peak of incidence of precursor lesions
to cervical cancer in women below 35 is proof that the screening
activities are effective in detecting in women in stages previous to
invasive cancer (Fig. 2)2,36,37.
Antioquia relies on a consolidated network of cytology laboratories,
led by the Public Health Laboratory of the State of Antioquia
and by means of the quality control Program, the awareness of
undergoing conventional cytology is improving, detecting cervical
cancer in pre-invasive stages, which is 100% curable. According to
the National Survey of Demographics and Health (or ENDS for its
acronym in Spanish) 201538 the practice of cytology in Antioquia
was 96.2% and the percentage of women who have not undergone
a cytology was 3.4%. This number confirms the wide coverage of
screening tests in the Antioquian population.
Limitations
The low proportion of registered cases based on non-microscopic
methods (2.5%) suggests that some cancer patients in the area were
not captured and the data is incomplete. The cause M:I is greater
than 1 in stomach cancers and in patients older than 70 with
prostate and breast cancer.
The data was obtained based on the population in the nucleus of the
municipality of Medellin. The technical and financial guidance was
provided by the Sectional Secretary of Health and Social Protection
of Antioquia. The project was led by a medical doctor, a pathology
specialist, an official of more than 30 years in this institution.
Acknowledgements
The authors manifest their acknowledgement to the team at the
Population Cancer Registry of Antioquia, to the Sectional Secretary
of Health and Social Protection of Antioquia and Dr. Luis Eduardo
Bravo of the Population-based Cancer Registry in Cali.
Conflict of interest:
Nothing declarated
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Table 2. Age standardized incidence rates (world population) of the principle types of cancer. Data comparison among the Population
Registries in Colombia.
RPC. Incidence Rates 2008-2012
Localizations Cali 32
Bucaramanga 33
Manizales34 Pasto35 Medellín (RPC-A)2010-2014
Men Women Men Women Men Women Men Women Men Women
Stomach 20.3 10.8 17.3 10.3 20.3 9.7 26.5 11.9 12.3 8.1
Prostate 60.1 41.1 44.1 27.1 38.6
Colon 10.5 9.7 9.5 9.9 8.4 10.0 4.5 5.4 7.0 6.4
Rectum 5.7 4.4 5.0 3.8 6.3 4.7 3.8 3.6 4.7 3.4
Breast 44.5 41.3 37.2 27.8 36.5
Cervix 15.4 12.9 17.5 18.1 8.5
All 205.0 185.7 153.7 156.5 156.0 164.8 134.1 145.6 144.4 145.6
VM% 86.7 89.8 81.5 88.0 85.8 84.7 83.3 84.4 97.4 95.5
DCO% 1.9 1.4 9.1 6.6 3.8 3.0 5.0 4.5 0.2 0.2
M:I¶¶ 55.3 53.3 68.3 60.7 74.6 68.8 63.8 52.6 72.3 62.5
Source: ¶ Cancer Incidence in Five Continents, Volume XI. Cancer Incidence in Five Continents, Volume X.

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gov.co/irj/go/km/docs/pccdesign/SubportaldelCiudadano_2/
PlandeDesarrollo_0_19/Publicaciones/Shared%20Content/
Boletines/Bolet%C3%ADn%20epidemiol%C3%B3gico%201%20
de%202015%20-%20C%C3%A1ncer.pdf
14. National Cancer Institute. Risk Factors for Cancer. Updated:
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15. Martinez LE, Saldarriaga RL. Hábito de fumar y estilo de vida
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163-169.
16. Martínez E, Quiroz CM, Cardozo FD, Montoya-Espinosa A.
Contaminación atmosférica y efectos en la salud de Medellín y su
área metropolitana. Medellín: Centro de Investigaciones Facultad de
Salud Pública Universidad de Antioquía; 2007 pp 79.
17. Rodríguez-Cuevas S, Macías-Martínez CG, Labastida-
Almendaro S. Breast cancer in Mexico. Is it a young women's
disease?. Ginecol Obstet Mex. 2000; 68: 185-190.
18. American Cancer Society. Breast cancer facts & figures 2011-
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acspc-030975.pdf.
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19. Adami HO, Malker B, Holmberg L, Persson I, Stone B. The
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23. Villarreal-Garza C, Platas A, Bargalló-Rocha J, Lasa F, Reynoso
N, Águila-Mancera C, et al. Cáncer de mama en mujeres jóvenes.
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files/ensin_2015_final.pdf.
27. Cortés A, Bravo LE, García LS, Collazos P. Incidencia, mortalidad
y supervivencia por cáncer colorrectal en Cali, Colombia, 1962-
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et al. Caracterización de 130 pacientes sometidos a gastrectomía por
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de Medellín. Rev Colomb Cancerol. 2016;20(2):73-78.
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34. Arias-Ortiz NE, De Vries E. Health inequities and cancer survival
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Colomb Med. (Cali) 49(1): 81-88

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Artículo original

Oncology services supply in Colombia

Servicios oncológicos en Colombia

Eliana Murcia1, Jairo Aguilera1, Carolina Wiesner2, Constanza Pardo3

1
Grupo Evaluación y Seguimiento de Servicios Oncológicos, Instituto Nacional de Cancerología, Bogotá. D.C., Colombia.
2
Dirección General, Instituto Nacional de Cancerología, Bogotá. D.C., Colombia.
3
Grupo Vigilancia Epidemiológica del Cáncer, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia.

Murcia E, Aguilera J, Wiesner C, Pardo C. Oncology services in Colombia. Colomb Med (Cali). 2018; 49(1): 89-96. doi: 10.25100/cm.v49i1.3620

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received:24 October 2017
Revised: 22 February 2018
Accepted: 21 March 2018
Keywords:
Health services; oncology
service, hospital; cancer;
Colombia.
Palabras clave:
Servicios de salud; servicio
de oncología en hospital;
cáncer; Colombia.
Objective: To characterize the current status of oncological services
supply in Colombia.
Methods: A descriptive analysis of oncological services for cancer
care in the adult and infant population that meet the requirements
for operation according to the Special Register of Health Service
Providers was carried out. The case – by - provider ratio was
calculated based on the cancer incidence estimated for Colombia by
the National Cancer Institute.
Results: Were identified 1,780 qualified oncology health services in
the country related to specialties for providing care to cancer patients.
Twenty five providers nationwide had all three qualified services:
chemotherapy, radiotherapy and surgery. Nearly 50% of the offer was
concentrated in Bogotá, Antioquia and Valle del Cauca. Putumayo
and the Amazonas group departments, with the exception of
Vaupés, did not show any oncological services. Healthcare Providers
were responsible for 87.8%, and independent professionals provided
12.2%. Outpatient services were 66.7% of oncology services, 17.4%
was diagnostic support services and therapeutic complementation,
and 15.9% was surgical services. 87.9% of the oncological service
offer in Colombia takes place in the private sector.
Conclusions: The ratio between the service groups is asymmetric,
with few providers jointly offering the basic services for oncology
treatment, which reflects how provision is fragmented. It is necessary
to redefine the concept of oncology service under a comprehensive
care approach and the importance of enabling functional units,
comprehensive treatment centers and other forms of care.
Objetivo: Caracterizar la situación actual de la oferta de servicios
oncológicos en Colombia.
Métodos: Se realizó un análisis descriptivo de los servicios oncológicos
para la atención de cáncer en población adulta e infantil, que
cumplieron con los requisitos para su funcionamiento de acuerdo
al Registro Especial de Prestadores de Servicios de Salud. La razón
de casos por prestador se calculó a partir de la incidencia de cáncer
estimada para Colombia por el Instituto Nacional de Cancerología.
Resultados: Se identificaron 1,780 servicios de salud oncológicos
habilitados en el país relacionados con especialidades para la atención
de pacientes con cáncer. 25 prestadores a nivel nacional contaron con
los tres servicios habilitados: quimioterapia, radioterapia y cirugía.
Cerca del 50% de la oferta se concentró en Bogotá, Antioquia y Valle
del Cauca. Los departamentos de Putumayo y del grupo Amazonas,
con excepción de Vaupés, no registraron servicios oncológicos. El
87.8% fue ofertado por Instituciones Prestadoras de Salud y el 12.2%
fue provisto por profesionales independientes. El 66.7% de los servicios
oncológicos eran de consulta externa, el 17.4% eran servicios de apoyo
diagnóstico y complementación terapéutica y el 15.9% servicios
quirúrgicos. El 87.9% de la oferta de servicios oncológicos en Colombia
está en el sector privado.
Conclusiones: La relación entre los grupos de servicios es asimétrica,
con pocos prestadores que ofertan de forma conjunta los servicios
bases del tratamiento oncológico, lo cual refleja la fragmentación en
la prestación. Es necesario redefinir el concepto de servicio oncológico
bajo el enfoque de atención integral y la importancia de habilitar
unidades funcionales, centros integrales de tratamiento y otras formas
de atención.

Corresponding author:
Constanza Pardo MSc, Grupo Vigilancia Epidemiológica del Cáncer,
Instituto Nacional de Cancerología, Calle 1 No. 9-85, Tel.: 57 (1) 4320160
extensión 4806, Bogotá D.C., Colombia. Correo electrónico cpardo@cancer.
gov.co.
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Introduction
About 14 million new cases of cancer1 were recorded in 2012, and
the number of cases with cancer incidence is expected to increase
by 70% over the next 20 years, facts that have made this disease
one of the main causes of morbidity and the second cause of death
in the world2, accounting for at least one in every six deaths. In
2015, cancer caused an estimated 8.8 million deaths; close to 70%
of deaths have been recorded in low and mid-income countries,
where less than 30% of countries provide treatment to patients
with an oncological pathology3.
Comprehensive care for cancer patients requires bringing
together the various oncological specialties - medical, surgical,
radio therapeutic - and it also requires the synergy of a variety
of diagnostic services (pathology, clinical laboratory, imaging,
nuclear medicine, among others) as well as that of clinical and
social support services (nutrition, mental health, social work,
pain control, among others) that are complementary4. According
to the recommendations made by high-income countries, which
have a high number of cancer patients, the oncological surgery,
radiotherapy and chemotherapy services should be concentrated
in comprehensive treatment centers, which can guarantee a high
volume of patients with the same pathology, thus allowing to justify
investment in complex treatment technologies, improve medical
expertise, and improve clinical outcomes. On the other hand,
diagnostic and patient support services must be decentralized5.
Colombia is a mid-income country, with a cancer incidence rate
of 151.5 per 100,000 men and 145.6 per 100,000 women6, with
a strong supply of oncological services in the private sector and
fragmentation among the services involved in cancer treatment4.
That is how, since cancer is a growing public health problem in
Colombia, the country placed the Ten-Year Plan for Cancer Control
2012-2021 as part of its public policies, where several goals were
defined, including: the need to update the eligibility standards and
the oncological services verification modes, as well as the need to
organize the service network for comprehensive care of cancer in
Colombia7. In meeting this goal, the procedures and conditions for
eligibility of health services, including oncology, were regulated in
2014, strengthening the requirements for compliance with quality
standards8.
In Colombia, the Ministry of Health and Social Protection has
the power to verify compliance with standards, and technical-
scientific conditions for opening and operating a new oncology
service, identifying this as a “qualified” service in The Special
Registry of Health Service Providers-REPS9. The REPS is the
official source of information on the registered offer of health
service providers that are authorized to provide health services
in each territorial demarcation, which, for the Colombian case,
are called departments, according to the political-administrative
division of the state. The country identifies two types of health
service providers: professionals who provide a single service
independently in their private offices and health services provider
institutions that offer several health services. The latter group
includes hospitals, clinics or similar establishments.
Based on this record, between 2004 and 2012 an increase in private
oncological services and an expansion of non-integral services
became evident, a fact that clearly showed fragmentation of care4.
90
As of 2012 and after the Ministry of Health and Social Protection
regulated the price of oncological medicines, there was a gradual
decrease in the number of services provided9, a scenario that
possibly slowed down the supply of new oncology services. This was
joined by a new national regulation defining the procedures and
conditions for registration and authorization of health services, as
well as the declaration of mandatory requirement for institutions
to obtain a verification by the Ministry of Health8 prior to opening
their oncological services8, even though the mandatory nature of
this verification does not imply that the Ministry regulates the
oncological service offering.
In order to avoid care fragmentation, aiming at promoting
comprehensive care under the model of units or comprehensive
treatment centers has been one of the ways in which the national
government has managed to organize the offer. New ways of
articulation between oncological services were defined by 2016:
Functional Units for Adult Cancer Care-UFCA and Childhood
Cancer Care Units-UACAI10, and the creation of Health Service
Suppliers’ Comprehensive Networks RIPSS, which the Oncology
Services Delivery Network is part of11. Within this context, the
objective of this article is to characterize the current oncological
services supply status in Colombia and its distribution by
departments for the year 2017.
Materials and Methods
A descriptive analysis of the distribution of oncology services that met
the requirements to provide health services for cancer care in the adult
and infant population in Colombia, which required prior verification
by the Ministry of Health and Social Protection for its operation was
conducted, according to information available in the REPS.
The set of oncological services included in the analysis is made
up of: outpatient services specialized in the medical and surgical
areas, surgical services, and diagnostic support and therapeutic
complementation services covering radiotherapy, chemotherapy
and nuclear medicine (Table 1)8. The information was consulted
with the report prepared by each department up to June 2017.
We conducted the search by using the “guest” user access profile. We
enter the “Current REPS” module, in the services item. Two search
criteria were used: name and code of the services of interest, according
to the service structure set forth in Resolution 2003 of 2014 (Table 1).
We carried out an information selection process, which included
all the oncological services registered in the REPS, except those
services that stated a “non-oncological” focus when registered,
that is, that the activities to be developed by them were not aimed
at dealing with cancer patients. The services corresponding to
“other” name codes were incorporated into the analysis only in
those cases in which the term oncological specialty was specified in
the service name. The variables defined in the analysis were those
related to geographical distribution, service group, legal nature,
type of provider, level of care, territorial character, complexity and
locations. Variables related to the provision mode were excluded
based on incomplete information.
The case-by-provider ratio was calculated from cancer incidence
data estimated for Colombia, information published by the
National Institute of Cancer - INC6, on the number of qualified
 Murcia E/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Table 1. Oncology services subject to prior verification by the provided 75% of the oncological offer; as for Santander, Bucaramanga
Ministry of Health and Social Protection. offers about half of all oncology services (48%) and the remaining offer
Group of services Service Service name is provided, in descending order, by the municipalities of Piedecuesta,
code
Floridablanca (Metropolitan Area) and Barrancabermeja.
210 Surgical oncology
227 Pediatric surgical oncology
Breast surgical oncology and soft tissue tumors
Offer of oncological services by type of provider, legal nature and
Surgical services group 232
surgery * level of care
237 Plastic surgery for the oncological patient Out of 1,780 qualified services provided in the country, 87.8%
217 Other surgeries* (1,563 services) was offered by Healthcare Providing Institutions
309 Pain and palliative care* - IPSs, and the remaining 12.2% (217 services) was provided by
336 Clinical oncology independent professionals - PI (Table 2).
346 Oncology rehabilitation
364 Breast and soft tissue tumor surgery* The IPSs group makes up 381 institutions and 443 care-providing
370 Plastic surgery for the oncological patient centers; this means that some of those IPSs enabled oncology
373 Surgical oncology services in more than one location. According to their legal
374 Pediatric surgical oncology nature, 91.1% of these institutions were private, 7.9% were public
375 Dermatological oncology
companies and only 1.0% were mixed entities. Regarding service
379 Gynecology oncology
Specialized Medical
381 Oncology and clinical hematology
provision, 362 IPSs (95%) stated to be medium and high complexity
Consultation group
390 Ophthalmic oncology and 19 low complexity IPSs. In addition, 21 IPSs recorded that
391 Pediatric hematology and oncology
they provide services in the third level of care, only 9 IPS in the
second level of care, and the rest of IPSs did not differentiate their
393 Orthopedic oncology
395 Urologic oncology
level of service provision.
408 Radiotherapy
383 Nuclear medicine*
As for the 347 existing private IPSs nationwide, they managed 1,374
394 Oncologic pathology of the 1,563 services authorized at IPSs, that is, 87.9% of the oncology
406 Hematological oncology services supply in Colombia is provided by private sector IPSs.
356 Other consultations*
709 Chemotherapy Public IPSs, which manage 180 services, correspond mostly to
Diagnostic and therapeutic 711 Radiotherapy institutions of departmental coverage (70%), and a smaller number
support Group
715 Nuclear Medicine (PET / Iodine therapy)* of entities have coverage at the national (10%), district (10%) and
* The REPS application has options for the provider to state whether the activities of
municipal (10%) levels. Likewise, the 30 public IPSs are entities
these services are aimed or not to cancer patients. Source: Resolution 2003 of 2014. that depend directly on the state or the departments, except for
two institutions belonging to the special regime of military health
oncological IPS. Calculations for 27 departments, the Capital and the national police.
District and the Amazonas group (Amazonas, Guainía, Guaviare,
Vaupés and Vichada) were made. In addition, the correlation Regarding independent professionals (195), it was found that
coefficient between new cancer cases per year and the number of several of them enabled more than one service or the same service
oncological IPS was calculated. in different locations. The average of independent professionals by
department is seven, it is important to note that in Arauca, Boyacá,
Results Casanare, Cesar, Chocó, Cundinamarca, La Guajira and San Andrés
and Providencia departments no oncology services enabled under
We identified 1,780 qualified health services in the national this type of providers (independent professionals) were found.
territory related to specialties for cancer patient care, as well as
close to 63,000 new patients per year, according to estimates of the In general, Colombia had 576 health service providers to serve the
INC regarding cancer incidences in the country. 62,818 new cases of cancer per year estimated in the country, with
an average of 2,166 cases of cancer per territory and 20 providers
Offer of health services by geographic location on average to meet this demand.
We found records of oncological services in 28 departments,
with at least one provider with an authorized service in each From the comprehensive care at the IPSs standpoint, there are an
territorial demarcation. The departments of Putumayo and the average of 13 IPSs per territory, with an average of 4.1 oncology
Amazonas group, with the exception of Vaupés, did not record services enabled per institution. This was the offer available for
any oncological services. Nearly 70% of the country’s offer was 165 new cases per year by IPS, with a range of variation between
concentrated in the Capital District, Bogotá D.C. (23.8%) and in 55 cases in institutions located in La Guajira and 1,052 cases to be
the departments of Antioquia (13.4%), Valle del Cauca (10.6%), addressed per IPSs located in Cundinamarca (Table 2).
Atlántico (8.3%), Santander (7.2%) and Bolívar (5.3%) (Fig. 1).
The number of new cancer cases estimated by department
With the exception of Chocó and Santander, capital cities in most showed a positive ratio with the number of oncology IPSs (r=
departments offered over 85% of oncological services available in 0.87). Some departments such as Antioquia, Valle del Cauca and
each territory. Bogotá, D.C., Medellin and Cali stood out as the Cundinamarca have new cases of cancer by IPS above the national
main urban centers with a high number of health services for average (165). The opposite is shown for the Departments of the
oncological diseases care. In the case of Chocó, its capital Quibdó Caribbean region and Santander (Fig. 2).

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Bogotá 337 86
Antioquia 202 36
Valle del Cauca 172 17
Atlántico 128 19
Santander 109 20
Bolívar 86 8
Risaralda 57 2
Magdalena 47 1
Nariño 42 1
Norte de Santander 40 4
Meta 39 4
Huila 36 3
Cesar 36
Córdoba 32 3
Tolima 31 2
Caldas 29 3
Sucre 28 1
Boyacá 25
Quindío 23 5
Cauca 18 1
Cundinamarca 16
La Guajira 15
Chocó 4
Caquetá 1
Grupo Amazonas 2
Casanare 2
Arauca 2
San Andrés y Providencia 1
Putumayo 0
0 50 100 150 200 250 300 350 400 450

Health Services Authorized in IPS* Health Services Authorized in PI**

Figure 1. Qualified Oncology Services by provider class and Department. Cut-off date: June 30, 2017. Source:
Database of the Special Register of Health Service Providers REPS. Ministry of Health and Social Protection.
* IPS: Institution providing health services,
** PI: Independent professional.

Table 2. Ratio between new cases of cancer and IPSs with oncology Offer according to health service groups
services in departments of Colombia. Cut-off date: June 30, 2017. When differentiating services according to the group classification
Estimated Oncology Cases/ *IPS structure, it was found that more than half of all oncology services
Department incidence IPS ratio were outpatient services (66.7%), and there was a lower percentage
Casanare 309 1 309 of participation in the offer for services related to the diagnostic
Antioquia 9,781 34 288
support and therapeutic support group (17.4%), and the surgical
Arauca 253 1 253
Boyacá 1,813 7 259 one (15.9%) (Table 3).
Cauca 1,521 6 254
Tolima 2,308 100 231 The outpatient group showed 1,187 services for 16 oncology specialties,
Valle del Cauca 7,639 353 218 among which clinical oncology, oncological gynecology, pain and
Córdoba 1,356 8 170 palliative care, and breast surgery and surgery of soft tissue tumors
Caldas 1,860 11 169 stands out because of their higher availability; these consultations
Norte de Santander 1,815 11 165 account for over 50% of the total offer of this group of services. 82.1%
Amazonas Group 164 14 164
of outpatient services were located in IPSs, and 17.9% of outpatient
Risaralda 1,723 11 157
Bogotá 11,068 72 154 consultations were provided by independent professionals.
Nariño 1,810 121 151
Caquetá 447 3 149 The diagnostic support and therapeutic support group are made
Quindío 1,172 8 147 up of services providing the traditional treatment modalities for
Huila 1,451 10 145 cancer: chemotherapy and radiotherapy and nuclear medicine.
Meta 1,206 9 134 In absolute figures, the services attached to this group were 310,
Chocó 279 2 140 discriminated as follows: chemotherapy (180), nuclear medicine
Sucre 737 67 123 (77) and radiotherapy (53). Participation of independent
Santander 2,961 25 118
Cesar 990 9 110
professionals in the offer of this group was 1.3%, which means that
Cundinamarca 3,157 3 105 98.7% of qualified diagnostic and therapeutic services in oncology
Magdalena 1,249 15 83 are provided by IPSs.
Bolívar 2,019 25 81
Atlántico 3,010 37 81 In addition, an offering consisting of six chemotherapy services
San Andrés y Providencia 78 1 78 was found in IPSs that did not have any outpatient services in
La Guajira 440 8 55 clinical oncology or hematology and pediatric oncology.
Putumayo 202 0 0
Colombia 62,818 38,118 165
Source: REPS database.* IPS: Institution providing health care services.

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12,000
Bogotá
R2 = 0.771

Antioquia
10,000

8,000 Valle del Cauca

New Cancer Cases (n)

6,000

4,000
Cundinamarca
Santander Atlántico
Tolima
Bolívar
Boyacá
2,000
Magdalena

La Guajira
0
0 10 20 30 40 50 60 70 80
IPSs Providing Oncology Services
Figure 2. Ratio of estimated incidence by departments and IPSs providing oncology services in Colombia. IPS:Institución prestadora de servicios de salud.
(Healthcare Provider Institution)

Table 3. Group of qualified (authorized) oncology services. Cut-off-date: June 30, 2017.
Number of services Number of services
Service group Service name enabled per IPS * enabled per PI**
Surgical oncology 105 0
Pediatric surgical oncology 20 0
Breast surgical oncology and surgery of soft tissue tumors * 122 0
Surgical services group Plastic surgery for the oncological patient 31 0
Other surgeries - Surgical oncology 3 0
Other surgeries- Gynecology oncology and mastology 1 0
Other surgeries- Orthopedic oncology 1 0
Pain and palliative care 132 15
Clinical oncology 182 37
Rehabilitation oncology 12 0
Breast and soft tissue tumor surgery 87 30
Plastic surgery for the oncological patient 24 8
Surgical oncology 83 21
Pediatric surgical oncology 10 0
Dermatological oncology 15 5
Gynecology oncology 113 44
Specialized medical
Oncology and clinical hematology 0 0
consultation group Ophthalmic oncology 13 4
Pediatric hematology and oncology 68 2
Orthopedic oncology 38 6
Urology oncology 33 10
Radiotherapy 46 14
Nuclear medicine 22 0
Oncologic pathology 0 0
Hematological oncology 87 8
Other consultations- Oncology 9 9
Diagnostic support Chemotherapy 180 0
and therapeutic Radiotherapy 51 2
complementation group
Nuclear Medicine (PET / Iodine therapy) 75 2
Source: REPS database.* IPS: Institution providing health services, ** PI: Independent professional.
**PI: Profesional independiente

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The surgical group showed a total of 283 services, where breast
and soft tissue surgery account for 43.1% of the total offered by
the group. Therefore, the availability of other surgical services,
in descending order, was: general oncological surgery (37.1%),
oncological plastic surgery (11.0%), pediatric oncological surgery
(7.1%), oncological gynecological surgery and mastology (0.4%),
oncological orthopedics surgery (0.4%), and other oncological
surgeries undifferentiated by specialty in the record (1.1%).
With regard to comprehensiveness of health services involved
in conventional forms of cancer treatment (chemotherapy,
radiotherapy, surgery), we found 257 providers offering these
services, of which 65.3% offered one of these three services,
therefore 88 providers only offered surgical oncology services, 77
providers only offered services to administer chemotherapy and
9 providers had radiotherapy services exclusively for diagnostic
support and therapeutic complementation. Also, a percentage of
24.9% of this group of providers offered two services for treatment,
which means that 49 providers had chemotherapy and oncological
surgery services, and 15 providers offered chemotherapy and
radiotherapy services. In summary, 25 providers nationwide had
the three services available: chemotherapy, radiotherapy and
surgery.
Discussion
This descriptive study presents the characterization of oncological
services in Colombia to provide care to cancer patients, based on
information available up to June 2017. A high concentration of
oncological services was found in the capital cities, out of which
more than half are related to outpatient services (67%) and 88%
of them are private. Only 25 providers nationwide had the three
services available: chemotherapy, radiotherapy and surgery.
Although the development of care models under the figure of
comprehensive units of care and networks has been deemed as
essential, it is worth noting that no records were found so far
regarding functional clinical units for adult cancer-UFCA, or units
for Comprehensive Care of Childhood Cancer UACAI, and also
no Comprehensive Networks for the Provision of Health Services
were found; according to this, thinking about a harmonization
of the service network in the different levels of complexity that
guarantees a quality and opportunity in the diagnosis of the
oncological disease is still somehow complicated; this clearly
shows the need the country has to classify and redefine what is
currently defined as an oncological service12.
The study clearly shows that there are large differences in the
number of new cases of cancer in different regions, and that the
largest numbers of cases are in the departments of Antioquia,
Atlántico, Valle del Cauca, Cundinamarca, and Bogotá. Incidence
estimates show that the demand for services varies according to
the geographical characteristics, and this reason would usually
consider that the offer of oncological services should be in
accordance with local demand. However, as it has already been
shown in the world, a case-by-case ratio of 165 cases per IPS per
year, as found in this study is very low to guarantee successful
health outcomes, considering that comprehensive treatment
centers such as the National Cancer Institute INC, handles about
7,000 new cases per year; nevertheless, this fact is special because
this is a reference institution that offers care to patients from
all over the country and does not segment its offer to regions4.
94
Likewise, countries such as the United Kingdom, which has an
incidence of 273 (APR per 100,000 person-years), states that
there must be a comprehensive treatment center for every 2.5 to
3.6 million people13, a concept that if brought to the Colombian
context, would mean having more or less 15 comprehensive
centers offering a multitude of oncological services, which is far
from the current situation in the country.
In the last decade, the offer of oncological health services in
Colombia showed a trend oriented to enabling services of the group
of consultation of oncological medical specialties, with second and
third places for services of diagnosis and therapeutic and surgical
complementation support; as a result of this dynamics, over half
of oncology services are outpatient services, more than 65% of
providers offering cancer treatment services tend to offer only
one type of service, and only 6.5% of IPSs have comprehensive
chemotherapy, radiotherapy and oncological surgery services. This
lack of balance in the ratio of service groups and the low average of
services provided by the IPSs suggests the existence of health centers
that do not integrate the basic oncological therapeutic modalities,
which hinders institutional coordination and sets up barriers to
access as well as quality in the care provided14.
Even though this article is not an analysis of sufficiency of
oncological services by specialty, since it includes variables
referring to the productive capacity of the services (infrastructure,
human talent, production, times and movements), the analysis
certainly showed that the gynecology and breast surgery services
as well as those for soft tissue tumors were the specialties with the
highest offer in consultation, data concomitant with the main types
of cancer in women (breast and cervix). In the case of oncological
gynecology, its high offer does reflect the priority granted to
providing care for the pathologies treated by specialty, therefore,
with the current offer, each authorized oncology gynecology
consultation service handles an average of 30 new cases of cervix
cancer per year out of the approximately 5,000 cases diagnosed;
nevertheless, breast consultation is not necessarily enabled for
cancer care, so the figures do not tacitly correspond to the offer for
treatment of an oncological pathology. In addition, if we consider
that of the 29,734 new cases of cancer per year that occur in men 6,
prostate cancer is the most frequent with around 9,000 cases, but
the offer of outpatient care for oncological urology was low, since
a consultation service for this specialty examines an average of 210
new cases of prostate cancer per year, a number that is far away
from the figure observed for women’s care.
Additionally, the record showed that, put together, the offer for
consultations of the oncological specialties of dermatology,
rehabilitation, ophthalmology, nuclear medicine and pediatric
surgery, does not account for more than 5% of the total offer of the
outpatient services group.
All the services of the surgical group were enabled by IPSs,
otherwise this would not be feasible, given the criteria of the
interdependence standard for qualification of surgical services
according to Resolution 2003 of 2014, a standard that regulates
qualification of health services. Some radiotherapy and nuclear
medicine services for diagnostic support and therapeutic
complementation were enabled by independent professionals;
however, given the requirements of the human talent standard
of the qualifying standard, this is a non-viable condition, since
 Murcia E/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
operation of these services involves several professionals and
therefore cannot be offered by a single independent professional.
This fact reflects discrepancies in the information system of the
registry of providers in the REPS.
In advanced oncological disease, pain relief and palliative care
is the only realistic treatment option that allows for improving
quality of life14. Palliative care along with other disciplines such as
rehabilitation, nutrition and mental health are fundamental areas
of care in all phases of the disease and make up the oncological
support services, as proposed by the Cancer patient care Model4;
thus, pain and palliative care consultation was the third most
offered and, among all consultations, oncological rehabilitation
was the third least offered, these figures show the need to
strengthen these support services. Although this deduction is
subject exclusively to the classification of services in the registry
of service providers, it does not exclude the fact that rehabilitation
is incorporated during the service provided, and that services are
recorded as “general” rehabilitation. Similarly, palliative care and
pain counseling are not exclusive in cancer treatment, so the offer
for this specialty in oncology may be overrated.
Strengths and limitations
The availability of an information system that allows characterizing
offer of health services in an up-to-date manner is a tool of great value
for all actors in the health system, including providers, patients and
decision-makers. This advantage makes it possible to differentiate
the oncological approach of some specialties in such a way that the
characterization of these services in particular turns out to be as close
as possible to the real offer available for cancer care.
However, the quality of the information contained in the registry of
providers has some irregularities. Data asymmetry is a limitation
that can be explained by the singularity in the registration
process of providers in the registry. One of the causes most often
observed is the possibility that providers have to register services
under codes framed in the so-called “other”, which is why many
specialties that provide outpatient and surgical services enable
their services in an undifferentiated way and generate the relative
divergences observed amongst the oncological subspecialties
offer. As an addition to this limitation, radiotherapy and nuclear
medicine services, both for outpatient consultation and diagnostic
support and therapeutic complementation, were registered years
ago under the same service code, which did not allow them to
be differentiated according to their clinical purpose. Therefore,
it is possible these services have not yet been updated to the
new registration codes and are wrongly classified. So, the data
presented should be dealt with exercising caution.
Finally, the data provided by the REPS showed some per se flaws
in the process of registration and verification of services, and this
limits the analysis of variables that can provide relevant data.
Therefore, it is required to update the information related to
service providers, so as to have a closer and more realistic view
of the real situation of the provision of oncological services in
Colombia.
Conclusion
Colombia is a country with a wide and extensive range of
oncological services throughout the national territory, with service
95
nuclei identified mainly in capital cities. The core of oncological
services offer is concentrated in private providers with a minimum
participation of public entities belonging to the Colombian state.
In general, the ratio between groups of services is asymmetric,
the majority of them being oncological outpatient services with
few providers that offer together the basic services for oncology
treatment, which reflects how fragmented provision is, a fact that
definitely does not benefit the patient. It is therefore necessary to
redefine the concept of oncology service under the comprehensive
care approach and the importance of authorizing or enabling
units, comprehensive treatment centers and other forms of care
that guarantee quality care with accessibility, comprehensiveness
and continuity. The capacity of oncological services for the current
and future needs of the country is not yet exactly known.
Conflicts of interest:
The authors state no conflicts of interest for this study
Funding:
This study was carried out with national resources of investment of
the National Institute of Cancer (National Cancer Network Program)
Referencias
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3. OMS. Cáncer. Datos y cifras. 2017. Acce3ssed: 21 July 2017.
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4. Murillo R, Wiesner C, Acosta J, Piñeros M, Pérez J, Orozco
M. Modelo de Cuidado del Paciente Oncológico. Bogotá D.C.:
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uk/wp-content/uploads/2017/10/national-cancer-transformation-
programme-2016-17-progress.pdf.
6. Pardo C, Cendales R. Incidencia, mortalidad y prevalencia de
Cáncer en Colombia 2007-2011. Bogotá D.C: Instituto Nacional
de Cancerología; 2015.
7. Ministerio de Salud y Protección Social, Instituto Nacional de
Cancerología E.S.E. Plan decenal para el control del cáncer en
Colombia 2012-2021. Bogotá D.C.; 2012.
8. Ministerio de Salud y Protección Social. Resolución 2003/2014
del 28 de mayo. Por la cual se definen los procedimientos y
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condiciones de inscripción de los Prestadores de Servicios de
Salud y de habilitación de servicios de salud. Diario Oficial,
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9. Dirección de Servicios y Atención Primaria. Registro especial de
prestadores de servicios de salud. 2017. Bogotá D.C.: Ministerio de
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from: https://prestadores.minsalud.gov.co/habilitacion/
10. Ministerio de Salud y Protección Social. Resolución 1477/2016
del 22 de abril. Por la cual se define el procedimiento, los estándares
y los criterios para la habilitación de las Unidades Funcionales
para la Atención Integral de Cáncer del Adulto "UFCA" y de las
Unidades de Atención de Cáncer Infantil "UACAI" y se dictan otras
disposiciones. Diario Oficial, número 49.852 (22/04/16); 2016.
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Nuevo/Resoluci%C3%B3n%201477%20de%202016.pdf.
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11. Ministerio de Salud y Protección Social. Resolución 1441/2016
del 21 de abril. Por la cual se establecen los estándares, criterios
y procedimientos para la habilitación de las Redes Integrales de
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[Internet]. Diario Oficial, número 49.851, (21/04/16); 2016;
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BibliotecaDigital/RIDE/DE/DIJ/resolucion-1441-2016.pdf
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Colomb Med. (Cali) 49(1): 89-96
 Suares MA/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Original Article
Pediatric oncology services in Colombia
Servicios de oncología pediátrica en Colombia
Amaranto Suarez Mattos, Jairo Aguilera, Edgar Augusto Salguero, Carolina Wiesner
Instituto Nacional de Cancerología, Bogota, Colombia
Suarez MA, Aguilera J, Salguero EA, Wiesner C. Pediatric oncology services in Colombia. Colomb Med (Cali). 2018; 49(1): 97-101. doi: 10.25100/cm.v49i1.3377
© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.
Article history: Abstract
Received: 17 July 2017 Background: In low-income countries, a child diagnosed with
Revised: 15 December 2017 cancer has an 80% chance of dying, while in high-income countries
Accepted: 12 January 2018 more than 80% survive the disease. In Colombia, a middle-income
country, the government issued new legislation that promotes the
Keywords:
generation of comprehensive care units; nevertheless, seven years
Medical care, comprehensive, after its expedition, no institution has been recognized as such by
children, cancer, Colombia
the Ministry of Health.
Objective: To characterize the current offer of oncological services
Palabras clave:
for cancer care in children and to identify the institutions that
Atención, integral, niños,
could be constituted in Units of Comprehensive Care of Childhood
cáncer, Colombia
Cancer in Colombia.
Methods: descriptive study of secondary source, it was consulted
the Special Register of Health Providers of the Ministry of Health
and Social Protection, in order to identify the institutions that had
enabled hospitalization services of medium or high complexity,
chemotherapy, specialized consultation, emergencies, oncological
surgery, radiotherapy or nuclear medicine. The information is
reported in absolute frequencies.
Results: Seventy one institutions have hematology-oncology
consultation, 39 institutions have chemotherapy and hospitalization
services of medium or high complexity, and 18 have radiotherapy
enabled. Only nine of the institutions include all the services that are
necessary for comprehensive care.
Conclusion: Colombia has a sufficient supply of services for the care
of children with cancer. Only a minority are in institutions that have
the capacity to guarantee the integrality of the attention.
Corresponding author:
Amaranto Suarez Mattos, Instituto Nacional de Cancerología . Cl. 1 #9-85,
Telefono +57 (1) 4320160. E-mail: asuarez@cancer.gov.co
97
Resumen
Antecedentes: En los países de bajos ingresos un niño diagnosticado
con cáncer tiene un 80% de probabilidad de morir mientras que en
los países de ingresos altos más del 80% sobrevive a la enfermedad.
En Colombia, un país de ingresos medios, el gobierno expidió una
nueva legislación que promueve la generación de unidades de atención
integral; sin embargo, siete años después de su expedición, ninguna
Institución ha sido reconocida como tal por el Ministerio de Salud.
Objetivo: Caracterizar la actual oferta de servicios oncológicos para
atención de cáncer en niños e identificar las instituciones que podrían
ser constituirse en Unidades de Atención Integral de Cáncer Infantil
en Colombia.
Métodos: estudio descriptivo de fuente secundaria, se consultó el
Registro Especial de Prestadores de Salud del Ministerio de Salud
y Protección Social; identificando las instituciones que tenían
habilitados servicio de hospitalización de mediana o alta complejidad,
quimioterapia, consulta especializada, urgencias, cirugía oncológica,
radioterapia o medicina nuclear. Se reporta la información en
frecuencias absolutas.
Resultados: Setenta y una instituciones cuentan con consulta de
hemato-Oncología, 39 instituciones tienen servicios de quimioterapia
y hospitalización de mediana o alta complejidad y 18 tienen habilitada
radioterapia. Solo nueve de las instituciones incluyen la totalidad de los
servicios necesarios para la atención integral.
Conclusión: Colombia cuenta con una oferta suficiente de servicios para
atención de niños con cáncer. Solo una minoría se encuentra en Instituciones
que tienen la capacidad de garantizar la integralidad de la atención.
 Suares MA/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Introduction
Cancer in children aged 0 to 14 is considered a rare disease, it
represents between 0.5% to 2% of all cancer cases in the world.
It is estimated that 200,000 new cases of cancer in children aged
under 15 are diagnosed annually worldwide1. 84% of children
dying from cancer live in countries with low or intermediate
income, where there is limited access to health care and cancer
care2. Clinical results differ substantially; while in low-income
countries a child diagnosed with cancer has an 80% chance of
dying, in high-income countries over 80% survive the disease3,4.
In Colombia, cancer is the second cause of death after deaths for
external causes in the group of 0-14 years of age5. Each year, 1,322
new cases of cancer are diagnosed6. In the five-year period 1990-
95 the survival of children with Acute Lymphoblastic Leukemia in
Colombia was 40.9%; and for the five-year period 2005-9, it was
53.8%. Although it shows an improvement, the results are much
lower compared to other countries in America7.
The differences in the results between the countries have a
multifactorial origin that involves a series of factors, such as the
social and economic determinants of each region6  Taking into
account that it is a pathology of low frequency and high complexity,
health systems need to organize their offer of services to guarantee
that access to the diagnosis and treatment of children with cancer
is concentrated in institutions that have specialized human talent,
biomedical technologies and the necessary infrastructure for the
complexity of care. In this sense, twinning programs between
hospitals located in countries with great experience and others
located in low-income countries have allowed to improve survival8,9.
In Colombia there have been multiple barriers to access timely
treatments for children with cancer: the delay by insurers in
the delivery of authorizations for care, the delay in the delivery
of medicines, and the fragmentation of services and inter-
institutional transfers to achieve comprehensive care10,11. Due to
these problems, the national government issued a new legislation
as legal support to reduce cases of death due to cancer in children
and persons aged under 1812,13. Colombian laws promote
comprehensive treatment and they have delegated the Ministry
of Social Protection to sector the services taking into account
the demand needs and geographical location. They also created
the National Advisory Council for Childhood Cancer to follow-
up and monitor the implementation of these laws, as well as the
national policies and plans that derive from it.
Within the framework of this regulation, the creation of Child
Cancer Care Units (CCCU) was defined as units “located in
hospitals or clinics of level III and IV of pediatric complexity,
or with pediatric services of level III or IV”12. The definition of
the concept of UACAI transformed the model of habilitation of
the pediatric oncological services towards a model in which the
provider institutions must guarantee the services related to the
care of children with cancer, in order to guarantee the integrality
in the attention and the optimization of resources13. However,
seven years after its dissemination, the country does not have any
UACAI recognized under that name by the Ministry of Health.
In this sense, this article makes a descriptive analysis of the offer
of institutions providing health services in Colombia that could
be constituted as Units of Comprehensive Care CCCU with the
purpose of promoting its implementation.
98
Materials and Methods
This is a descriptive operational study that uses the Special
Registry of Health Providers (SRHP) of the Ministry of Health and
Social Protection as a secondary source, consulted on August 29,
2016: This registry is permanently updated by the territorial health
entities, which makes it changeable in time.
To identify the institutions that provide health services (hereafter
referred as  IPS) that can be constituted in CCCU, the technical
annex “Manual of Habilitation” was taken from the Ministry
of Health and Social Protection, which considers three central
standards: organization or structure, management and health
outcomes13. The study defined in its scope of the first standard
“Organization of the CCCU”.
The Habilitation manual describes the services with which CCCU
meets the requirement of “it may provide” and have available for its
conformation: medium or high complexity hospitalization service
and chemotherapy service. In the same way and as a criterion in
the identification made in this study, the provider institutions that
were enabled in the REPS services were taken into account such
as: Specialized external consultation, emergencies, oncological
surgery, radiotherapy or nuclear medicine.
The search was parameterized taking into account the following
variables: group of services, service code, name of the provider,
level of complexity, legal nature of the provider and province. The
search was oriented to IPSs and not to independent providers; the
search profile used was guest, the codes of the services consulted
were: 391 oncology and pediatric hematology consultation,
374 pediatric surgery consultations, 227 pediatric oncological
surgeries, 709 chemotherapy, 711 radiotherapy, 715 nuclear
medicine, 102 pediatric general hospitalizations, 501 emergency
services.
The search strategy in the REPS focused on the following route:
1. Identification of the initial universe of providers that prescribe
treatments in pediatric oncology: providers who had one of the
following services enabled: pediatric hematology and oncology
consultation and pediatric surgery consultation.
2. Identification of qualified chemotherapy services in any form
of ambulatory or hospital care and pediatric hospitalization of
medium or high complexity.
3. 
Identification of support services and therapeutic
complementation of radiotherapy or nuclear medicine.
4. Identification of emergency services and pediatric oncological
surgery. This last result was converted for the study into the final
input that shows the potential number of institutions providing
health services that can structure their services under a care
strategy as CCCU (Fig. 1).
For the analysis there were simple frequencies obtained by
province and by service. In a progressive manner, there were
institutions excluded that did not have all the services that from a
theoretical rather than a regulatory point of view should constitute
an UACAI, such as pediatric hospitalization, outpatient oncology
 Suares MA/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

IPS with pediatric consultation of: The Province of Atlántico registers 13 institutions, a greater
Oncology, hematology and surgery. number than other Provinces that have capital cities with similar
Universe of Presenters with Pediatric Services (71 IPS) characteristics, such as Antioquia or Valle del Cauca, which register
a lower number of IPS, six and seven respectively; that way Atlántico
reports just the same number of IPS than the City of Bogotá D.C.
(Bogotá represents the entire Province of Cundinamarca).

IPS with hospital or outpatient chemotherapy and
Pediatric hospitalization of medium or high complexity (39 IPS)
IPS with radiotherapy or nuclear medicine services (21 IPS)
Among the 71 Healthcare Provider Institutions (IPS), 39
institutions distributed in 15 Provinces “have/may provide”
chemotherapy and hospitalization services of medium or high
complexity (Table 1). The Provinces that did not meet the search
criteria for hospitalization services of medium and high complexity
and chemotherapy were Cesar, La Guajira, Magdalena and Meta.

Of the 39 registered IPS with qualified hospitalization services

IPS with emergency services and pediatric
oncological surgery. Potential UACAI (9 IPS)
Figura 1. Algorithm describing the results of the number of health service providers (IPS) in
each of the searches carried out.
of medium or high complexity and chemotherapy, the ones
that had support services and therapeutic complementation of
radiotherapy or nuclear medicine were verified, being identified
a total of 21 IPS distributed in 11 Provinces (Table 2). As it can
be seen, 18 IPS have enabled the radiotherapy service, 12 of them
have enabled the nuclear medicine service and nine have the two
services described above.

The number of institutions that met the requirements to establish

and pediatric hematology consultation and pediatric surgery
consultation, chemotherapy in any form of ambulatory or hospital
care and hospitalization, radiotherapy or nuclear medicine,
emergencies and pediatric oncological surgery.
Results
According to the SRHP as of the cutoff date of August 29, 2016,
there were 71 Provider Institutions of Health Services identified,
“Universe” of the country that has specialized consultation of
oncology and hematology or consultation of oncological surgery for
pediatric cancer care; they are distributed in 19 of the 32 provinces
of the country. 69 IPS have a pediatric oncology and hematology
consultation, and 11 also include oncological surgery (Table 1).
themselves as CCCU were reviewed, that is to say, that they had the
services to guarantee the integrality in the diagnosis and treatment
of children with cancer. Table 3 shows that 9 of the IPS (located in
the Provinces of Atlántico, Santander, Valle del Cauca and Bogotá
City) met the criterion of concentrating the greatest number of
services in the same physical space. In relation to this, however, only
four of the nine IPS comply with pediatric oncological surgery offer,
eight with radiotherapy and seven with nuclear medicine.
Discussion
This study makes an analysis of the offer of pediatric cancer services
in Colombia that fulfill the guarantees to establish a diagnosis and
comprehensive treatment for patients with cancer. According to

Table 1. Distribution by province of IPS with authorized services of pediatric oncological consultation, pediatric hospitalization of
medium or high complexity and chemotherapy.
IPS with Oncology and IPS with hospitalization IPS with both consultation
Province Number of IPS* IPS with oncologic surgery
hematology and chemotherapy services
Antioquia 6 6 4 0 0
Atlántico 13 12 5 2 1
Bogotá D.C** 13 12 9 4 3
Bolívar 3 3 3 1 1
Caldas 2 2 1 0 0
Cesar 2 2 NR 0 0
Córdoba 2 2 1 0 0
Huila 2 2 1 0 0
La Guajira 2 2 NR 0 0
Magdalena 1 1 NR 0 0
Meta 1 1 NR 0 0
Nariño 1 1 1 0 0
Norte de Santander 3 3 1 0 0
Quindío 1 1 1 0 0
Risaralda 4 4 3 0 0
Santander 4 4 3 2 2
Sucre 3 3 1 0 0
Tolima 1 1 1 0 0
Valle del Cauca 7 7 4 2 2
Total Colombia 71 69 39 11 9
Source: SRHP August 2016. Elaboration: self-made (study team)
* IPS with some service enabled under the SRHP service codes: 391, 374.
** Bogotá D.C. represents the Province of Cundinamarca.

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the study, it is found that of the 71 qualified institutions, that is, Table 2. Distribution by province of IPS with oncological consultation
guaranteed to offer oncological services for children with cancer, services, medium and high complexity pediatric hospitalization,
only 21 of them have hospitalization, a chemotherapy room, a chemotherapy, radiotherapy and/or nuclear medicine.
Hematology-oncology clinic and a pediatric oncological surgery Province
Number of
Radiotherapy
Nuclear
Both services
clinic; and only 9 (12%) of the institutions are able to guarantee the IPS Medicine
integrality of that care in Colombia. Antioquia 2 2 2 2
Atlántico 2 2 NR NR
High-income countries have defined the criteria that cancer Bogotá D.C 6 3 6 3
centers must fulfill in order to be able to offer care for inpatients Córdoba 1 1 NR NR
and outpatients diagnosed with childhood cancer. Emphasis Huila 1 1 NR NR
has been placed on the fact that the facilities must ensure timely Quindío 1 1 NR NR
Risaralda 1 1 NR NR
accurate diagnosis, the administration of intensive chemotherapy,
Santander 2 2 NR NR
emergency management for serious complications 24 hours a day,
Sucre 1 1 1 1
intensive care services, and timely and complete blood support
Tolima 1 1 NR NR
(blood bank) among others, and to have a network of hospitals
Valle del Cauca 321 3 3 3
that offer treatments as part of a shared attention14-16. This shared Total Colombia 21 18 12 9
network is important because the radiotherapy service is not always Source: SRHP August 2016.
found within the hospitals, and this does not stop the care from SRHP: Special Registry of Service Providers of the Ministry of Health and Social
Protection
being comprehensive, as long as the care is guaranteed if required, IPS:Institución prestadora de servicios de salud. (Healthcare Provider Institution)
particularly for cases of central nervous system tumors. This is the
case of the hospital network in Chile under the PINDA program16.
Faced with the objectives set in Colombia since 2010 11, the goal
Human talent is an essential requirement and institutions must of implementing comprehensive care for children with cancer has
have a multidisciplinary team led by pediatric hematologist/ not been achieved. In the first place, it is found that the resolution
oncologists with the support of pediatricians, subspecialists defining the rating of UACAI was only published in July 2016 12.
in some areas of pediatrics, pediatric surgeons, intensive Secondly, the authorization is voluntary, which means that the
pediatricians, rehabilitators, nurses and other professionals13,14. institutions do not have a motivation to do so, since a great effort
Since the number of cases of pediatric cancer is relatively low, to have all the required services is required. On the other hand,
the quality of treatment is guaranteed when the same institution it is allowed that the UACAI be located in centers of “medium
receives a significant volume of children with cancer. complexity,” and that they may have services outside the same
institution, which is a bit against the objective of having integral
Likewise, there must be available educational programs for patients treatment centers; with the exception of the service of radiotherapy,
and family members, school programs, including contact with which can certainly be shared by several institutions. This is how
teachers who teach students at home or hospital, as well as support the regulation states, for example, that the hospitalization service
with reincorporation to school, and social support programs to may be available outside the (health) institution if it only has
help families with their concerns about economic difficulties and ambulatory surgery enabled12.
about the treatment and expenses that are going to be incurred17.
A critical element that negatively affects the care of children and
Without compliance with these minimum conditions, it is very adolescents with cancer is that it allows potential CCCU not to have
difficult for children, adolescents and young adults to benefit 24-hour emergency services in the pediatric hematology-oncology
from the progress made in high income countries, due to the fact units as a requirement for habilitation, which is fundamental for
that an accurate diagnosis, adequate treatment, and medical and the care of children. In this regard, Dang-tan  et al.19, reported
social support care depend on a multidisciplinary team and an on the delays in the diagnosis of pediatric solid tumors that, in
infrastructure enabled in the institutions to treat cancer. general, the diagnosis was timelier when patients with suspicion
of cancer were treated for the first time in an emergency service.
According to the present study, 19 out of the 32 Provinces of On the other hand, and more importantly, is the need to have an
Colombia have a pediatric oncology service enabled, and these are immediate service for the complications caused by diseases or
concentrated in six provinces (Bogotá, Atlántico, Valle del Cauca, treatments that may endanger the lives of cancer patients.
Antioquia, Santander and Risaralda) which is adequate taking into
account that Cancer in children is a rare pathology. It is striking that Taking into account that the only source of information for
the Province of Atlántico, with a population approximately four times performing this study was the REPS, there are some limitations
smaller than the city of Bogotá, has the same number of institutions because only information related to infrastructure could be
with oncology services enabled. As a possible explanation to this included; the REPS does not allow to identify certain requirements
situation, it is found that most of the institutions that offer these demanded as “central of mixtures” or “program of pain and
services are private institutions that offer a broad service portfolio palliative care”; in the first case, the REPS does not identify these
regardless of their ability to guarantee integral conditions in the care physical environments; in the second case, it does not identify
of children with cancer. In Colombia, the authorization of health programs. The fact of being the only source of information
services has been allowed, such as outpatient services, chemotherapy constitutes its main weakness. It is desirable to supplement the
or hospitalization of children with cancer; without the need for information with other primary sources. It is also possible, even
them to be integrated within the same institution, which hardly though it is little feasible, for many providers to register authorized
guarantees a comprehensive and continuous care18. services that are not offering or that are inactive.
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 Suares MA/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Table 3. Distribution by Province of IPS with oncological consultation services, hospitalization and chemotherapy, radiotherapy or
nuclear medicine, pediatric surgery and emergency service.
Province Number of IPS Oncology and hematology
Atlántico 2 2
Bogotá D.C 2 2
Santander 2 2
Valle del Cauca 3 3
Total Colombia 9 9
Source: SRHP August 2016
IPS: Institución prestadora de servicios de salud.
Conclusion
It is found that Colombia has an adequate offer of oncological
services for children with cancer; however, this offer only
guarantees the integrality requirements in a small proportion.
Conflict of interest:
Nothing
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6. Pardo C, Cendales R. Incidencia, mortalidad y prevalencia de
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de Cancerología. Biomédica. 2012;32:355-64.
11. Suárez A, Guzmán C, Villa B, Gamboa. Abandono del
tratamiento: una causa de muerte evitable en el niño con cáncer.
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12. Ministerio de Salud y Protección Social. Ley 1388 de 2010.
“Por el derecho a la vida de los niños con cáncer en Colombia.
Bogotá: Ministerio de Salud y Protección Social; 2010.
13. Ministerio de Salud y Protección Social. Resolución 1477 de
2016. “Por la cual se define el procedimiento, los estándares y los
criterios para la habilitación de las Unidades Funcionales para la
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Atención de Cáncer Infantil "UACAI" y se dictan otras disposiciones.
Bogotá: Ministerio de Salud y Protección Social; 2016.
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Standards for pediatric cancer centers. Pediatrics. 2014;134(2):410-4.
15. American Academy of Pediatric: Organizational principles to
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16. Campbell M. Desarrollo de la oncología pediátrica en Chile.
Rev Ped Elec. 2005; 2(2): 1-4.
17. European Society for Paediatric Oncology. European Standards
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18. Ministerio de Salud y Protección Social. Resolución 2003. Por la
cual se definen los procedimientos y condiciones de inscripción de
los prestadores de servicios de salud y de habilitación de servicios
de salud. Bogotá: Ministerio de Salud y Protección Social; 2014.
19. Dang‐Tan T, Franco EL. Diagnosis delays in childhood cáncer.
Cancer. 2007; 110(4): 703-13.
Colomb Med. (Cali) 49(1): 97-101
 Pardo C /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Original Article

Breast and cervical cancer survival at Instituto Nacional de Cancerología, Colombia

Supervivencia de cáncer de mama y cuello uterino en el Instituto Nacional de Cancerología, Colombia

Constanza Pardo1 and Esther de Vries2

1
Cancer Surveillance Group, Instituto Nacional de Cancerología, Bogota, Colombia.
2
Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia.

Pardo C, De Vries E. Breast and cervical cancer survival in Instituto Nacional de Cancerología, Colombia. Colomb Med (Cali). 2018; 49(1): 102-108. 10.25100/cm.v49i1.2840

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 11 January 2017
Revised: 19 February 2018
Accepted: 06 March 2018
Keywords:
Breast cancer, cancer of
the uterine cervix, survival
analysis, hospital-based,
registry, Colombia
Palabras clave:
Cáncer de mama, cáncer
de cuello uterino, análisis
de supervivencia, registro
hospitalario de cáncer,
Colombia
Objective: to provide and compare estimations of two-year overall
survival for cervical and female breast cancer in three cohorts (first
treated in 2007, 2010, 2012) at the Instituto Nacional de Cancerología
of Colombia
Methods: All patients first treated at the Instituto Nacional de
Cancerología for breast or cervical cancer in the years 2007, 2010,
2012, without a prior cancer diagnosis, were included for the
study. The hospital-based cancer registry was crosslinked with
governmental databases to obtain follow-up information on all
patients. Probability of surviving 24 months since the date of entry
at the hospital was estimated using Kaplan-Meier methods, using the
log-rank test to evaluate differences between groups.
Results: We analyzed 1,928 breast cancer cases and 1,189 cervical
cancer cases, resulting in an overall survival probability at 24 months
of 79.6% (95% CI: 77.8-81.4) for BC and of 63.3% (95% CI: 60.6-
66.0) for cervical cancer, there were no differences in survival for year
of entry. Advanced clinical stage substantial affected overall survival,
being 32.2% (95% CI: 28.4-44.0) for stage IV breast cancer and 22.6%
(95% CI: 11.4-33.8) for stage IV cervical cancer.
Conclusions: Breast cancer was the cancer with the best survival at
Instituto Nacional de Cancerología; cervical cancer the one with the
lowest survival. Overall survival did not change over the years for
any of the cancers.
Objetivo: Describir las estimaciones de supervivencia global a dos
años para mama (mujeres) y cuello uterino en tres cohortes (tratadas
por primera vez en 2007, 2010, 2012) en el Instituto Nacional de
Cancerología de Colombia.
Métodos: Se incluyeron las pacientes tratadas por primera vez en el
Instituto Nacional de Cancerología por cáncer de mama y de cuello
uterino en los años 2007, 2010, y 2012, y quienes no habían tenido un
diagnóstico previo de otro cáncer. Se cruzaron las bases de datos del
registro hospitalario de cáncer con las gubernamentales para obtener
información de seguimiento de los casos. Se estimó la probabilidad
de sobrevivir a 24 meses a partir de la fecha de ingreso mediante el
método de Kaplan-Meier. Se aplicó la prueba de rango logarítmico
para evaluar las diferencias entre los grupos.
Resultados: Se analizaron 1,928 casos de cáncer de mama y 1,189 de
cuello uterino. La estimación de la supervivencia global a 24 meses para
mama fue 79.6% (IC 95%: 77.8-81.4) y de 63.3% (IC 95%: 60.6-66.0)
para cuello uterino, no se observaron tendencias en supervivencia con
el año de ingreso. En los estadios clínicos avanzados la supervivencia
global disminuyó en estadio clínico IV, tanto para cáncer de mama,
32.2% (IC 95% 28.4-44.0), como para cuello uterino 22.6% (IC 95%
11.4; 33.8).
Conclusiones: El cáncer de mama presentó mejor supervivencia en el
Instituto Nacional de Cancerología frente al cáncer de cuello uterino.
La supervivencia global se comportó de manera estable con los años
para ambos tipos de cáncer.

Corresponding author:
Esther de Vries Department of Clinical Epidemiology and Biostatistics. Cra 7
No 40-62 Hospital San Ignacio. Piso 2, Bogotá, Colombia. Tel: (57-1)320 8320
Ext. 2813 Fax: (57-1) 320 8320 Ext. 2800. Email: estherdevries@javeriana.
edu.co
102
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Introduction
The cancer burden among women in Latin-America is mostly
attributable to breast and cervical cancers1-3. In 2012 in Latin-
America, age-adjusted breast cancer incidence rates reached levels
between 40-65 per 100,000 woman-years. Age-standardized breast
cancer mortality rates in Colombia increased substantially: from
6.9 in the mid-1980´s (6.9) to 10.8 in 20124-6. Age-standardized
cervical cancer mortality rates have come down from 13.2 in
1984-1988 to 8.7 in 20136.
The Instituto Nacional de Cancerología of Colombia (INC)
estimated that in the period 2007-2011, around 7,600 new breast
cancer cases were diagnosed annually, with 2,226 annual breast
cancer deaths. In the same period, there were 4,462 new cervical
cancer cases, and 1861 deaths. Both cancer types show strong
geographical variations between different parts of the country,
with breast cancer being more frequent in the cities and urbanized
areas, and cervical cancer in the remote areas7.
The prognosis of these two cancer types depends on
sociodemographic characteristics but even more on the stage at
diagnosis, the available therapeutic options and the efficiency of
the system in providing (access to) care. In general, cancer survival
improves with Human Development Index (HDI) of countries or
regions, probably through better access to efficient treatments and
potentially early detection. Colombia is currently categorized as a
high HDI country (0.720)8. Since 2003 the coverage of Colombia’s
‘universal’ mandatory health insurance system has increased
substantially. This system consists mainly of two different regimes,
each covering slightly under 50% of the population, in which
people are assigned on the basis of income: the contributory
regime, covering workers and their families with an income
above the cut-off and financed through the payroll and employer’s
contributions and the subsidized regime, covering those identified
as ‘poor’. Additionally, around 5% of the population, workers in
the petrol industry, teachers, military and police, is affiliated to
“special” and “exceptional” regimes; and is a remaining group of
the population not being covered by the system (representing 2.6%
in 2015, according to the Ministry of Health)9,10. The insurance
packages and methods are similar, but not equal between regimes
and providers within each regime.
There are few available data on survival of these cancer types in
Latin American populations; the few population-based data do
not show survival by stage11,12. Trends in survival in hospital-based
settings are scarce13, with most existing reports aiming to determine
the efficiency of the different therapeutic options. INC Colombia
designed a survival surveillance system, based on linkage with
government databases, to produce comparable overall survival
estimates of its patients on an annual basis, with the objective of
evaluating changes in prognosis over time and contributing to the
improvement of the quality of cancer care within the institution
and, through comparison of data, on a national level.
In this manuscript we compare the demographical and clinical
characteristics of breast and cervical cancer patients treated at
INC in the years 2007, 2010 and 2012 and report 2-year overall
survival estimated by age, clinical stage and type of affiliation to
the social security system.
103
Materials and Methods
All female invasive breast (C50) and cervical cancer (C53) cases
first treated at the Colombian INC in the years 2007, 2010 and
2012 were selected from the hospital-based cancer registry of
the INC14. Only the first primary invasive cancer was considered
for each cancer, as the probability of survival of patients with
previous primaries may be altered. The cases registered in each
year were considered fixed cohorts. The hospital registry data was
checked and completed using medical records and linked with
the hospital-based mortality database as well as government-
based information sources such as the National Civil Registry
(Registraduría Nacional del Estado Civil (RNEC)) to determine
vital status at December 31st 2014 and date of death for deceased
patients who died extramurally. This was necessary as the
Colombian legislation does not allow direct linkage between our
patient databases and the cause- and date of death registry; if one
has the personal identification number, it is possible to check for
vital status and reporting of deaths in RNEC. Two-year overall
survival was calculated for the cohorts of women entering INC
in 2007, 2010 and 2012, with start date of follow-up being the
date of entry at INC. Date of death was specified according to the
death certificate in case this certificate was available, for those
patients reported as deceased in the RNEC but without detailed
date of death, we determined the expected date of death as the
date of reported deceased at RNEC minus a correction factor.
This correction was calculated based on data of deceased patients
with available death certificates, where the real date of death
was compared with the date of reporting in RNEC; the median
difference between these dates was subtracted from the RNEC
date to obtain expected date of death15. This median number of
days of difference between date of death and reporting of the death
decreased over time (for breast cancer it was 148 days in 2007,
66 in 2010 and 25 in 2012; corresponding number of days for
cervical cancer were 184, 114 and 39 days), indicating substantial
improvements in the reporting systems. The detailed steps to
determine date of last contact or date of death are described in
detail elsewhere, and summarized below15.
As this process is a bit complex, we described it in more detail below:
a) For patients who deceased within INC, the exact date of death
was known and assigned.
b) For patients with unknown vital status, we used the Colombian
personal identification number (cédula) to check for vital status
in the databases of the RNEC - RNEC reports if persons are
deceased. If the patients did not appear as “deceased” in any of the
RNEC data sources, the 31st of December 2014 was assigned at
date of last follow-up.
c) For those cases reported as deceased in RNEC but without death
certificate information, the date of death was estimated based on
the date of reporting of the death in RNEC, corrected for the
median difference between date of death and date of reporting of
death at RNEC, as described above and in detail elsewhere15. If this
procedure resulted in negative survival times, the date reported in
RNEC was assigned as date of death. This procedure generated the
variable: calculated date of death.
 Pardo C /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Table 1. Demographic and diagnostic characteristic of the study populationby cohorts

Breast cancer Cervical cancer
Characteristics
n (%) 2007 2010 2012 n (%) 2007 2010 2012
Total number 1,928 100 622 (32.3) 632 (32.8) 674 (35.0) 1,189 100 387 (32.5) 474 (39.9) 328 (27.6)
Age (yrs)
0 - 14 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
15 - 44 344 (17.8) 118 (19.0) 102 (16.1) 124 (18.4) 400 (33.6) 119 (30.7) 167 (35.2) 114 (34.8)
45 - 54 609 (31.6) 189 (30.4) 199 (31.5) 221 (32.8) 293 (24.6) 102 (26.4) 97 (20.5) 94 (28.7)
55 - 64 493 (25.6) 158 (25.4) 165 (26.1) 170 (25.2) 262 (22.0) 86 (22.2) 116 (24.5) 60 (18.3)
> 65 482 (25.0) 157 (25.2) 166 (26.3) 159 (23.6) 234 (19.7) 80 (20.7) 94 (19.8) 60 (18.3)
Social Security Scheme
Contributive 764 (39.6) 228 (36.7) 236 (37.3) 300 (44.5) 286 (24.1) 86 (22.2) 85 (17.9) 115 (35.1)
Subsidized 525 (27.2) 119 (19.1) 219 (34.7) 187 (27.7) 573 (48.2) 154 (39.8) 289 (61.0) 130 (39.6)
Special 168 (8.7) 50 (8.0) 50 (7.9) 68 (10.1) 45 (3.8) 9 (2.3) 9 (1.9) 27 (8.2)
Particular 256 (13.3) 90 (14.5) 80 (12.7) 86 (12.8) 98 (8.2) 30 (7.8) 39 (8.2) 29 (8.8)
Uninsured 215 (11.2) 135 (21.7) 47 (7.4) 33 (4.9) 187 (15.7) 108 (27.9) 52 (11.0) 27 (8.2)
Clinical stage
I 111 (5.8) 26 (4.2) 43 (6.8) 42 (6.2) 289 (24.3) 106 (27.4) 112 (23.6) 71 (21.6)
II 545 (28.3) 168 (27.0) 196 (31.0) 181 (26.9) 250 (21.0) 92 (23.8) 104 (21.9) 54 (16.5)
III 751 (39.0) 259 (41.6) 248 (39.2) 244 (36.2) 418 (35.2) 121 (31.3) 173 (36.5) 124 (37.8)
IV 141 (7.3) 34 (5.5) 54 (8.5) 53 (7.9) 54 (4.5) 14 (3.6) 21 (4.4) 19 (5.8)
No information 380 (19.7) 135 (21.7) 91 (14.4) 154 (22.8) 178 (15.0) 54 (14.0) 64 (13.5) 60 (18.3)

d) For those cases deceased according to RNEC but with only year of
death known (no month or day available in RNEC), we assigned the
30th of June of the provided year as date of death for patients with
date of entry in the first semester of a year, and 31st of December if
patients entered INC in the second semester of a year.
e) For those cases for whom none of these methods could be
applied, or who were not identified in the mentioned databases,
the last date of follow-up was assigned as the date of the last visit
according to the medical file at INC.
Statistical analysis
In order to assess differences in distribution of clinical stage by type
of affiliation to the Colombian social security system, we performed
Fishers exact test. Survival time was calculated as the difference
between the closing date of follow-up (December 31st, 2014), date
of last contact or calculated date of death and the date of entry at
the INC. The probability of surviving 24 months was calculated
using Kaplan-Meier analysis, and differences in survival by several
90
Two years over all survival estimates (%)
variables were assessed using the log-rank test. Univariate analyses
were performed for year of entry, age in two categories (<50 y ≥50
years), clinical stage and type of affiliation to the social security
system at the moment of entry at INC. Because of violation of the
proportional hazard assumption for the variables year, age group,
and type of affiliation to the social security system, we did not report
results of the multivariate Cox Proportional Hazards models. All
data were analyzed using SPSS®, v19.
Results
Demographic and clinical characteristics of the patients
We analyzed a total of 1,928 breast and 1,189 cervical cancer
patients.  Table 1  shows the characteristics by cancer type and
cohort; the distribution between breast and cervical cancer was
shifting towards breast cancer over time. Breast cancer cases were
concentrated in the 45-54 years age group, and cervical cancer in the
15-44 years age group. The percentage of patients not affiliated to the
social security system decreased between 2007 and 2012 for both

80

70

60

50

40

30

20

10

0
2007 2010 2012 2007 2010 2012
Breast cancer Cervix uteri cancer.
Figure 1. Comparison of two year overall survival estimates for breast and cervical cancer by cohort

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Table 2. Distribution of cancer stage by type of affiliation to the social security system

Contributive Subsidized Uninsured Special Private

Tumour stage
% % % % %
Breast cancer stage
I 8.2 2.1 2.3 12.5 4.3
II 32.1 25.1 22.3 35.8 23.4
III 35.0 51.1 48.8 29.2 24.2
IV 6.9 8.6 13.5 3.0 3.5
No information 17.8 13.1 13.0 19.6 44.5
Cervical cancer stage
I 26.9 25.2 20.3 31.1 16.3
II 21.7 21.1 21.4 20.0 18.3
III 33.5 35.7 42.8 24.4 26.5
IV 5.2 4.4 5.4 2.2 3.0
No information 12.6 13.6 10.2 22.2 35.7
p-values for differences in stage distribution by regimen: Breast cancer: p= 0.01034, cervical cancer p <0.005

cancer types. There was an important proportion of cases without
clinical stage information (19.7% for breast cancer, 15.0% for cervical
cancer); 100% of cases had a histologically confirmed diagnosis.
Overall survival
Two-year overall survival did not vary between the different
cohorts, as shown in Figure 1.
Breast cancer
The 1928 patients in the analyses had a median age at entry in
INC of 55 years (range 17-99). Most (66%) patients were aged over
50 and most of them (39.6%) were affiliated in the “contributive”
regime of the social security system. About half of the patients
had stage III-IV breast cancer at entry in INC. Stage distribution
differed substantially and statistically significantly between
regimes, with around 60.0% of women in the subsidized and
uninsured groups being diagnosed in stages III-IV, versus 42.0%
in the contributive and around 30.0% in the special regime and
privately insured group (Table 2).
At 24 months of follow-up, 393 (20.4%) had died, the remaining
1,535 cases were censored at follow-up. Two-year OS for breast
cancer was 79.6%, with clear differences in survival between types
of affiliation to the social security system, being highest for those
in the “special” regime (93.4%) (log-rank test 48.9, p <0.001). Few
patients died in the first month of follow-up (1.9%). Two-year OS
of stage I patients was very high (98.2%), declining to 36.2% for
stage IV patients. No significant effects were found for year of or
age at entry at INC (Table 3, Fig. 2).
Cervical cancer
The median age of the 1,189 women with cervical cancer was 51
years (range 19-92). Most were aged over 50, almost half (48.2%)
were affiliated to the subsidized part of the social security system,
and almost 50.0% of patients presented at INC with stage I or II
disease. The distribution by stage was similar between regimes,
with between 40 and 50.0% of women being diagnosed in stages
I-II, with the exception of the privately insured women (34.6%),
who had a significantly better stage at entry (Table 2). At the end
of the two years of follow-up, 435 (36.6%) had died, the remaining
754 cases were censored. The probability of surviving two years

Table 3. Univariate overall survival estimates of breast cancer and cervical cancer by cohorts
Breast cancer Cervical cancer
Number of Number of
Characteristics N % Surviving** CI 95% Log-rank test N % Surviving** CI 95% Log-rank test
deaths* deaths*
Total 1,928 393 79.6 77.8 - 81.4 N.A. 1,189 435 63.3 60.6 - 66.0 N.A.
Years of entry at INC
2007 622 32.3 122 80.4 77.3 - 83.5 X2= 4.1 387 32.5 135 65.0 60.3 - 69.7 X2= 3.7
2010 632 32.8 142 77.4 74.1 - 80.7 p= 0.127 474 39.9 177 62.6 58.3 - 66.9 p= 0.161
2012 674 35.0 129 80.8 77.9 - 83.7 328 27.6 123 62.3 57.0 - 67.6
Age (years)
<50 655 34.0 138 78.9 75.8 - 82.0 X2= 0.5 539 45.3 173 67.8 63.9 - 71.7 X²= 17.6
≥ 50 1273 66.0 255 80.0 77.8 - 82.2 p= 0.481 650 54.7 262 59.5 55.8 - 63.2 p= 0.000
Social Security Scheme
Contributive 764 39.6 147 80.8 78.1 - 83.5 X²= 48.9 286 24.1 102 64.2 58.7 - 69.7 X²=6.0
Subsidized 525 27.2 131 75.0 1.3 - 78.7 p= 0.000 573 48.2 201 64.8 60.9 - 68.7 p= 0.202
Special 168 8.7 11 93.4 89.7 - 97.1 45 3.8 16 64.4 50.5 - 78.3
Particular 256 13.3 52 79.6 74.7 - 84.5 98 8.2 46 52.6 42.6 - 62.6
Uninsured 215 11.2 52 75.8 70.1 - 81.5 187 15.7 70 62.4 55.3-69.5
Clinical stage
I 111 5.8 2 98.2 95.6 - 100.7 X2= 404.9 289 24.3 28 90.3 87.0 - 93.6 X2= 229.5
II 545 28.3 30 94.5 92.5 - 96.5 p= 0.000 250 21.0 61 75.6 70.3 - 80.9 p= 0.000
III 751 39.0 171 77.2 74.3 - 80.1 418 35.2 217 47.6 42.7 - 52.5
IV 141 7.3 90 36.2 28.4 - 44.0 54 4.5 41 22.6 11.4 - 33.8
No information 380 19.7 100 73.6 69.1 - 78.1 178 15.0 88 50.6 43.3 - 57.8
*Number of deaths in two years follow up
**Probability of surviving 2 years
N. A.= not applicable

105
 Pardo C /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Breast cancer
a) b)
1 1
0.9 0.9
0.8 0.8
0.7 0.7

Global survival
0.6 0.6

Global survival
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 0 2 4 6 8 10 12 14 16 18 20 22 24
Time (months) Time (months)
I II III VI No information Contributive Subsidized Uninsured Special Particular

Cervix cancer
a) b)
1 1.0
0.9 0.9
0.8 0.8
0.7 0.7

Global survival
Global survival

0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 0 2 4 6 8 10 12 14 16 18 20 22 24
Time (months) Time (months)
I II III VI No information Contributive Subsidized Uninsured Special Particular

Figura 2. Función de supervivencia a dos años (Kaplan – Meier) por estadio clínico y seguridad social, para
cáncer de mama (a y b) y de cuello uterino (c y d).

was 63.3%, with a better survival for women presenting at younger a bit lower than reports from USA-based studies, undoubtedly
ages (67.8%). During the first month of follow-up, 2.3% of patients related to a relatively late stage at entry in our patients, with 46%
died. There was a sharp gradient in survival by clinical stage at of women with stage III/IV disease.
presentation, between 90.3% in stage I and 22.6% in stage IV.
The quality of the Colombian death registry has improved
No differences in survival was observed by year or type of social substantially in recent years18, limiting, but not eliminating,
security (Table 3, Fig. 2). the possibility that some patients may have died without being
registered. In this case, the patient will have been censored alive
Discussion at her last visit in INC, which may have slightly over-estimated
survival rates. The improved quality is also reflected in the
These results are among the first of the overall survival surveillance diminishing of the time between date of death and reporting of
project of the INC; showing a stable two-year overall survival death in RNEC.
for breast and cervical cancer with the expec562-year survival
for breast (80%) and cervical cancer (63%) is not far from the The age distribution of our patients was as expected19,20. For the
population-based reports from Cali (3-year OS:breast 77%, cervix prognosis of breast cancer, early detection is important, as well as
63%)12. Survival in a specialized cancer hospital is expected to the time between first symptoms or abnormal screening test and
be a bit lower than the population-based survival data, because first consultation (according to a previous Colombian study this
specialized centers tend to receive “complicated” patients referred was >1 month in 34.1% of the patients) and the time between the
from other, less specialized hospitals. first consultation and treatment initiation (in 69.8% of patients
>3 months in a previous study)21. Cervical cancer patients were,
One limitation of our study is that we have no reliable incidence as expected, relatively young, and a substantial proportion (40%)
date, and therefore we had to use date of entry at the INC. The presented with late stage disease, a situation that could have been
survival time calculated from the date of diagnosis is certainly prevented by effective screening programs.
higher than our reported survival data, although we cannot know
how much higher: some patients come for their initial treatment to Unfortunately, we did not have information on clinical stage for
the INC - their date of entry will be close to their date of diagnosis; an important proportion of our patients (breast cancer 19.7% and
others come when initial treatment has failed or when they have cervical cancer 15.0%). However, our observations of around 50%
a recurrence, sometimes a long time after their initial diagnosis. of women being diagnosed in stage III/IV breast cancer and 40%
Considering this, our reported survival rates for cervical cancer in stage III/IV cervical cancer, despite this proportion of missing
are relatively similar to European estimates, lower than of the USA values, shows the very late stage at presentation of our patients. As
but higher than those for Brazil 11,12. Breast cancer survival is quite the proportional hazards assumption was violated, we did not run
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 Pardo C /et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
multivariate survival models. However, the differences in stage
distribution by regime of affiliation, with lower stage at diagnosis
of breast cancer in the contributive and special regimes as well
as privately insured women, explains the differences between
survival curves for breast cancer. Likewise, for cervical cancer, the
better survival of the privately insured is most likely due to the
earlier stage at diagnosis in this group of patients.
It is important to have a baseline idea of hospital-based cancer
survival, to evaluate tendencies and be able to act when necessary.
Counting with reliable data on cancer occurrence, stage and
survival is necessary for effective cancer control, at local and
national level.
Conclusion
Breast cancer and cervical cancer have, for international standards,
a poor survival, and this survival has not improved over time.
The late stage at diagnosis undoubtedly plays an important role
in these relatively poor results and could be improved through
changes in the early detection programs offered in Colombia.
The statistically significant differences in clinical stage by type of
affiliation to the social security system is reflected in the survival
rates and shows the enormous potential for improvement in access
to early detection, diagnosis and treatment of these cancer types.
Acknowledgements:
We would like to thank Jenny Patricia Castro for her help in
searching and updating the information of the hospital-based
registry and linking the follow-up information.
Conflicts of interests:
We have no conflicts of interests to declare
Funding:  Filho A, Vazquez Vde L. The Hospital de Câncer de Barretos
This work was performed with financial support of the Instituto
Nacional de Cancerología allocated to the Cancer Surveillance
programme of this institution
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Colomb Med. (Cali) 49(1): 102-108

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 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Technical report

Cali cancer registry methods

Métodos del Registro de Cáncer en Cali, Colombia

Luz Stella García1, Luis Eduardo Bravo1,2, Paola Collazos1, Oscar Ramírez1,4,5, Edwin Carrascal1,2, Marcela Nuñez1, Nelson Portilla1,
Erquinovaldo Millan3

1
Registro Poblacional de Cáncer de Cali. Cali, Colombia
2
Departamento de Patología, Facultad de Salud, Universidad del Valle, Cali, Colombia.
3
Secretaria de Salud Pública Municipal de Cali, Cali, Colombia.
4
Fundación POHEMA. Cali, Colombia
5
Sistema de Vigilancia Epidemiologica de Cáncer Pediátrico (VIGICANCER), Cali, Colombia

García LS, Bravo LE, Collazos P, Ramírez O, Carrascal E, Nuñez M, Portilla N, Millán E. Cancer Registration in Cali, Colombia. Colomb Med (Cali). 2018; 49(1): 109-120.
Doi: 10.25100/cm.v49i1.3853

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Received: 20 December 2017
Revised: 30 January 2018
Accepted: 13 February 2018
Keywords:
Cancer registry, methods,
data management, Cali,
Colombia
Palabras clave:
Registro de cáncer, métodos,
manejo de datos, Cali,
Colombia
Background: The Cali Population Registry of Cancer Registry of Cali
(RPCC) has operated since 1962, disseminating high quality information
to provide a framework to assess and control the burden of cancer in Cali.
Methods: The collection of new cancer cases in permanent residents
of Cali is done through active search in and notification from hospi-
tals, and public and private laboratories. The Secretary of Municipal
Public Health provides individual information on general mortality
and death from cancer. Tumors are coded with ICDO-3 and mortality
with ICD-10. Presented rates are standardized by age and trends are
assessed by estimating the percentage annual change using the regres-
sion analysis in JoinPoint. The 5-year net survival was analyzed with
the Pohar-Perme estimator.
Results: 88.5% of the registered cancers had morphological verifica-
tion (MV). The proportion of unknown primary site represented 5%
and the death certificate only cases (DCO) varied between 0 to3% de-
pending on the cancer site. All deaths were certified by a physician,
94.2% of cancer deaths were correctly certified. The ill-defined site
proportion was 5.3% and that of uterine cancer not specified (C55)
was 0.5%. For survival analysis, existing data collection procedure
and infrastructure ensures assessment of the patient’s vital status and
follow-up, with an average lost to follow-up of 13.2%.
Comment: The information has been published in the eleven volumes
of "Cancer Incidence in Five Continents" confirming high quality of
the collected data. The RPCC PCRC has also participated in the Con-
cord Study and is participating in SURVCAN-3.
Antecedentes: El Registro Poblacional de Cáncer de Cali (RPCC)
opera de manera continua desde 1962 divulgando información
de calidad para proporcionar un marco para valorar y controlar
el impacto del cáncer en Cali.
Métodos: La recolección de los casos nuevos de cáncer en
residentes permanentes de Cali se hace mediante búsqueda
activa y por notificación en los hospitales y laboratorios públicos
y privados. La Secretaria de Salud Pública Municipal proporciona
la información individual de mortalidad general y por cáncer.
Los tumores se codifican con la CIO-3 y la mortalidad con la
CIE-10. Las tasas se estandarizan por edad y la tendencia se
estudia con el porcentaje de cambio anual y con la regresión
de JoinPoint. La supervivencia neta a 5 años se analizó con el
estimador de Pohar-Perme.
Resultados: El 88.5% de los canceres tuvieron verificación
morfológica (VM). La proporción de los casos codificada
como de sitio mal definido representó el 5% y el certificado
de defunción como única evidencia del diagnóstico de cáncer
(DCO) varió entre 0-3% dependiendo de la localización. Todas
las defunciones fueron certificadas por un médico, el 94.2% de
las muertes por cáncer fueron bien certificadas. La proporción
de sitio mal definido fue 5.3% y la de cáncer de útero no
especificado (C55) fue 0.5%. En todos los casos de supervivencia
fue posible el seguimiento y la proporción de censuras fue 13.2%
Comentario: La información ha sido publicada en los once
volúmenes de “Cancer Incidence in Five Continents”. El RPCC
participó en el Estudio Concord y está participando en SURVCAN-3.

Corresponding author:
Luz Stella García, Registro Poblacional de Cáncer de Cali. Calle 4B 31-00
Oficina 4003, Edificio 116, Cali, Colombia. E-mail: luz.garcia@correounivalle.
edu.co
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 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Introduction
The Population Cancer Registry of Cali (RPCC) was started in
1962 as a research program of the Department of Pathology of
the Universidad del Valle. It was initially funded by a donation
from the Ana Fuller Fund. Later, La Universidad del Valle became
the main source of both financial and scientific resources of the
registry. The RPCC began at the same time as Pan American
Health Organization (PAHO) conducted the Urban Mortality
Study, which examined in detail all the death certificates of the
city 1. The systematic study of these certificates was part of the data
collection for the RPCC2.
Cancer registries are systems that collect information in a
continuous and systematic way about each new cancer case
identified within a specific population in a given area and period3.
There are two types of cancer registries that complement each
other, although they have distinct procedures and objectives: the
population-based cancer registry (PBCR) and the hospital-based
Cancer Registry (HBCR). The HBCR records all cases that go to
a health center or specialized service, regardless of their place
of residence, for administrative and patient care purposes. The
purpose of the PBCR is to identify all new cases of cancer that appear
among the inhabitants of a well-defined, natural or administrative
demographic area. The main objective is to produce information
to provide a framework to assess and control the impact of cancer
on health of the community. Some registries might be specialized
on one or several tumor location(s) are called Monographic;
and can be both hospital-based and population-based. Central
cancer registries gather and consolidate information from several
registries that cover different areas, which can also be population-
based or hospital-based3.
The value of the modern cancer registry and its ability to carry out
cancer control activities depend to a large extent on the underlying
quality of its data and the established quality control procedures4.
In this article, the Population-based Cancer Registry of Cali shows
a standardized methodological guide and maintains the quality
criteria for a reliable information system to estimate the burden
of cancer in Cali.
Rural area of Cali
Urban area of Cali
Figure 1. Cali-Valle del Cauca-Colombia geopolitical map. License: http: //creativecommons.org/licenses/by-sa/3.0/deed.es Modified by: Tejido
creativo Cali-Colombia
110
Obtaining new cases of cancer
Population and registration area
Cali is the third largest city in Colombia, capital of the Province of
Valle del Cauca, located by the Cauca river valley at coordinates
3°27’00” N 76°32’00” W. The western limit is the Farallones of Cali,
which are part of the Western Cordillera of the Colombian Andes.
According to both the 2005 census and National Administrative
Department of Statistics of Colombia (DANE) projections, the
estimated population for 2010 was 2.3 million inhabitants, 52%
are women, and 26.2% self-identify as belonging to the black
ethnic group5,6. The life expectancy at birth was 73.1 years for
men, and 78.5 years for women7. The facilities for oncological care
includes165 oncology services8, located in the urban area, where
95% of the population resides in an area of ​​110 km2. This area
corresponds to 20% of the extension of the municipality of Cali
(561.7 km2)9; Administratively Cali was divided into 22 communes,
with a gross density of 4,094.7 inhabitants/km2. The rural land
is approximately 424.4 km2  (divided into 15 corregimientos or
designated areas)  9 with a gross density of 0.83 inhabitants/km2.
In 2012, the municipality of Cali was defined as the cancer registry
area. The geopolitical map is shown in Figure 1.
Case definition
People of any age, residents in the urban area of ​​Cali, with
a diagnosis of invasive malignant tumor for the first time
(incident), of any anatomical location, that has been confirmed
or treated in partial or in total. The basis for diagnosis can be both
microscopic (fluid cytology, peripheral blood and bone marrow,
histology of primary tumors and autopsy); and non-microscopic
(clinical, surgical and imaging diagnosis). The following cancers
were included: single or multiple primary malignant tumors, all
tumors of the Central Nervous System and  in situ  breast and
cervical cancer. Excluded are benign tumors with uncertain
behavior, malignant tumors of metastatic sites, and basal cell
and epidermoid carcinoma of the skin (these were included until
1986). The cases that arrived in the city for treatment or diagnosis
purposes are not considered residents of Cali.
Yumbo
Rural
area of Cali
Palmira
Rural
area of Cali
Urban
area of Cali
Communes (administrative division)
Health care center
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Pediatric cancer
In 2009, an information system was setup within the RPCC for
the continuous monitoring of clinical outcomes of children
with cancer treated in Cali (VIGICANCER). Details have been
published earlier  10. In summary, the system, in addition to the
registry of incident cases, actively follows children under 19
years old treated in pediatric oncology units in Cali. The system
includes both residents of the city and patients referred from
other municipalities and departments. As part of the RPCC, it
also receives information from secondary sources, achieving
an exhaustiveness of around 94% and a follow-up of 95% of
registered cases. The outcomes under surveillance are the vital
status, relapses, abandonment of treatment and second primary
cancers. This system continues to monitors patients who leave
treatment and, if their vital status is unknown, they are included
as events for survival analyzes. The observed survival is reported,
using the Kaplan-Meier method.
Comparability of the basic data collected
The basic information for the RPCC is collected in a pre-coded
form that includes data of the person: name, sex, date of birth, age,
and address. Neoplasms are described with anatomical location,
morphology, behavior and, degree of differentiation, multiple
primary tumors, the extent of disease (breast and cervix) and the
most valid basis of cancer diagnosis.
For the last 20 years, information on the outcomes has been
collected: date of last contact, vital status, date of death, and cause
of death. Neoplasms in adults are coded with ICDO-311, whereas
in children with ICCC-312.
To calculate date of incidence we used the guidelines of the
European Network of Cancer Registries (ENCR)13  and this
corresponds to the date of the first histological or cytological
confirmation of cancer. For the classification of multiple primary
tumors, the IARC / IACR guidelines14 were used, which are also
used elsewhere around the world, to report the incidence rates.
Confidentiality of information
The guidelines of the European Network of Cancer Registries
(ENCR)13 are followed. The director of the RPCC is responsible
for the security of the information. All the staff members of
the RPCC sign an agreement to guarantee the protection of
the confidentiality of the data on the persons whose cancer
is informed to the RPCC. Access to the physical space of the
Registry is restricted to authorized persons only. The access to the
confidential information is carried out using personal passwords
that permit access to the computers holding the classified
information and additionally closed files are used. Any data that
is not used is automatically destroyed.
A single person (administrator) makes initial matching between
databases to detect new cases and update vital status information.
A registration number is assigned to each case and the information
that identifies a patient is deleted before the data is analyzed
(name and other documents that can lead to identification of the
patient).
Facilities
Universidad del Valle has been the main source of financial
and technical resources. The research group at RPCC has a
111
head quarter (287 m² area) with 15 employees working in the
registry. The head of staff and his advisors are senior researchers
and pathology professors at the School of Medicine. The
coordinator is a business administrator with a master’s degree
in epidemiology and the information system is managed by an
engineer with a master’s degree in engineering with emphasis in
systems engineering and computer science. There are three data
collectors. The staff has job stability due to university affiliation
that provided permanent contracts. The RPCC assures stability
to the rest of the human resources using specific projects funds.
The Information Technology network includes an intranet
with Internet access supported by the Office of Information
Technology and Telecommunications of Universidad del Valle.
The local network includes a server, 11 computers and 5 laptops.
Backup copies are made twice a day by means of an automatic
daily script and a monthly external copy. The technical team
of the RPCC meets weekly to resolve the problem cases. The
software of the RPCC (Siscan) performs consistency checks when
entering the data and the internal consistency is checked every
six months with IarcTools15. Before sending the information to
international collaborators or external projects such as the IARC
and the CONCORD program, the whole data set is rechecked
with IarcTools15.
Periodic survey of medical specialists
The three-yearly survey of medical specialists in the city is a key
activity in which several groups of students from the Faculty of
Health of the Universidad del Valle have participated. This survey
lasts for eight weeks and complements the continuous cancer data
collection by the RPCC. As an initial step, the inventories of sites
that have oncological services for the diagnosis and treatment of
cancer that are not covered during routine collection activities
are updated. The Faculty of Health of the Universidad del Valle
is contacted, and the participating students are trained in biology,
cancer nomenclature, and the methodology standardized to
obtain cancer cases. Each participant is assigned a supervisor
(member of the RPCC) and support materials are provided that
include: 1) General recommendations; 2) minimum variables for
collection; 3) list of malignant tumors; 4) manual for completing
the form of the cancer morbidity survey; 5) list of assigned
specialist physicians; 6) cover letters; and 7) collection forms. The
supervisor has permanent contact to clarify doubts and concerns
and receive weekly update of the information collected.
Procedure for obtaining new cases of cancer
Figure 2 summarizes the procedures for collecting information to
obtain new cancer cases among permanent residents of Cali. The
information is in physical format and structured and unstructured
digital formats; and the extraction of the variables of interest is
done in several phases manually or automatically.
Figure 3 shows the procedures for detection of duplicate cases,
multiple tumors, updating vital status, date of last contact,
residence and identity of each new case of cancer. The procedures
involved three phases, which are as follow:
Phase 1. Extraction of information
This is done through active search and manually when the
information is in physical format and structured and unstructured
digital formats; or automatic to obtain structured and unstructured
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Linkage Linkage

Clinical and Data source:

Diagnostic Death Certificates
Hospital Public & Paper or Private Physicians
Labs
Private Electronic Forms

Triennial Annual

Diagnostic
Linkage Cali
Labs Periodic
Continuous Population-based
Collection Cancer Registry Collection

Discharges
Linkage
Summaries
3. Eliminates potential
Duplicate records

Figure 2. Population Cancer Registry of Cali (RPCC). Procedure to obtain new cases of cancer among permanent residents of the city through active
search and notification. Collection is continuous in diagnostic laboratories, hospitals and clinics; public and private. The collection is periodic (annual
and three-yearly) in the Municipal Public Health Secretariat (for death certificates), and in the physician office´s. The information is integrated into the
database of the RPCC, through individual search or with matching between databases (linkage).

Extraction list

WORD PDF EXCEL PLAIN

Phase 1
Extraction and Linkage
Linkage

Yes No Approximate
Exact Search ID Number
Search

R.P.C.C

Phase 2
Phase 3
Update
Incidence Case
No
Registered Search

Health Yes
Insurance Health
Insurance
No more No Get
Found Search
Information Mortality ID Verification
Mortality

Yes Discharges Discharges

Summaries Summaries
Clerical Review
Merge IARC 2004 (1)
Notification Berg (2) Rules
Systems Notification
Systems

Multiple
Identification Residence Vital Status Tumor

Record with input No

Found
data
No
Flag:
Yes No Identification
Alive
Residence Yes
Vital Status Yes

Complete
Update Duplicate
Identification

Residence

Vital Status

Incidence
Case

Figure 3. Exact search procedures (personal identity document) to detect duplicate cases, multiple tumors, update vital status, date of last contact,
residence and identity of each new case of cancer.

listings. Hospital expenditures are obtained periodically in a
structured digital format. With an automatic process of data
extraction, for each case a matching with the database of the
Population Cancer Registry is done in two methods: Exact search
(Fig. 3) and Search by approximation (Fig. 4).
112
Phase 2. Update of the information
When the cases already exist in the base of the RPCC (prevalent
cancers), additional information is sought in the health insurance
databases (public and private), general mortality in the city, and
hospital discharges from clinics and hospitals in Cali. Information
of identification, residence, date of last contact and vital state is
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Aproximate Search
Extraction
list
RPCC
Dataset A
Splitting
Cleaning and
Standardisation
Blocking
Indexing
Field
Comprasion
Weight Vector
Classification
Matches
Figure 4. Approximate search procedures when there is no personal identity document.
Pairing with the Population Cancer Registry database using the approximate search method
recovered; these updated variables are marked as completed
(Flag) and the case is excluded for future searches. The revised
rules of the IARC 200414 is used to allow detection of multiple
primary tumors.
Phase 3. Inclusion of new cases
In phase 3, cases that are not found in the main database of the
cancer registry are processed. First, the three additional data
sources are searched (Fig. 3) to find additional information that
allows identification, residence and vital status to be completed.
Afterwards they are entered into the main database as a new case
of cancer (incidence). If additional information is not retrieved in
the auxiliary databases, the case enters with only the data obtained
in the extraction phase.
Search by approximation
It is used when there is no information on the personal
identification document (Fig. 4). The two sets of data to be
compared are prepared namely data set (A) that are the extraction
lists which contains the possible new cases of cancer and data set
(B) which is the database that contains the information system
of the RPCC. First the data set is divided into smaller groups to
optimize matching, then standardized and indexed by blocks of
similarity between two fields (names and date of birth), finally
a weighted vector classification is made, where a threshold
of similarity, the result is two groups of records: those that are
estimated as potentially equal and those that are considered as a
possible match whose process continues with a manual review,
the records are evaluated to be paired between the two data sets 16.
113
Linkage
Health Discharges
Mortality
Insurance Summaries
Dataset B
Names
Surnames Strong
Field
Date of birth
Address
Optional
Phone Field
Number
Possible
Non Matches Clerical Reviewt
Matches
Evaluation Flag
Procedures for the analysis of incidence and mortality
The International Classification of Diseases (ICD-10)17 is used for
the coding of cancer. The main locations were defined according
to the guidelines suggested by the IARC for the analysis of the
incidence information; and by the WHO to group the primary site
of the tumor and the causes of (cancer) death18,19. The structure of
the population by sex and five-year age groups for each calendar
year was obtained in the DANE5. The incidence and mortality
rates for the entire population were standardized by age (ASR) by
means of the direct method, using as reference the world standard
population20,21. The global and specific rates by age and sex are
expressed by 100,000 person-years. Trends in incidence rates were
analyzed over ten 5-year period from 1962 to 2012; and those of
mortality during six five-year periods, from 1984 to 2015. The
summary measures to assess the trend of the rates over time was
the annual percentage change (APC), calculated by the minimum
method weighted squares22. For some locations and age groups it
was impossible to estimate the APC because in some years there
were no new cases or cancer deaths in these categories.
Procedure for survival analysis
Selection criteria
Individual data from 38,671 permanent residents of Cali during
the period 1995-2009, aged between 15 and 99 years, with a
diagnosis of a first invasive malignant tumor in one of the following
fourteen locations defined by the ICD-10 were included for the
analysis. (WHO, 2012): Stomach (C16), colorectal (C18-C20),
liver (C22), lung (C34), melanoma (C43), breast (C50), cervix
(C53), ovary (C56), prostate (C61), thyroid (C73), Hodgkin’s
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

lymphoma (C81), non-Hodgkin’s lymphoma (C82-C85, C96),
multiple myeloma (C90), and leukemia (C91-C95). Following
the Concord-2 study guidelines23, the groups of solid tumors
were defined by the anatomical site and the leukemias by their
morphology. The coding of the topography and morphology was
done with the International Classification of Disease for Oncology,
third edition (ICD-O-3)11. All malignant haematopoietic diseases
were included according to the range of morphological codes of
the ICD-O-3 from 9.590 to 9.999.
Excluded from the survival analysis are tumors identified as  in
situ, benign or of uncertain behavior, subjects with unknown
ages, tumors detected during necropsy, cases diagnosed only
through death certificate, and the syndromes myelodysplastic and
myeloproliferative neoplasms such as chronic myeloid leukemia.
Patients with synchronous bilateral breast cancer were included
and treated as individual cases for the analysis.
Event definition, start and end date
Death from any cause was considered an event in the survival
analysis. The survival time of each case was determined by the
difference in time (in days) between the date of diagnosis (index
date) and the date of death, the date of last contact, or the date of
the end of the study, which was defined as December 31, 2009.
To compare the survival changes during the study period, the 15-
year study period was divided into three: a first period between
January 1, 1995 and December 31, 1999 that coincided with the
implementation of the health reform in Colombia; and the other
two periods; 2000-2004 and 2005-2009; after the implementation
and consolidation of Law 100.
Follow-up: To update the vital status and the date of last contact,
links were established between the RPCC information system and
the following databases: a) general mortality of the Municipal
Public Health Secretariat of Cali; b) hospital discharges from Level
III institutions; c) Identification System for Potential Beneficiaries
of Social Programs (SISBEN, 2016); and d) Private health
insurance companies (2014). Process is described in Figures 3 and ​
and44.
Analysis plan
The response variable was the time between the diagnosis of cancer
and the death of each individual. The maximum observation time
for each subject for the failure to occur was five years. The censored
variable was applied for patients who did not present the fault
within the study period, and as a mechanism of censorship the loss
was established during the follow-up and the end of the study. For
the analysis, survival times greater than five years were censored,
times after the loss to follow-up and / or as of December 31st, 2009.
For the five-year periods 1995-1999 and 2000-2004, a cohort
analysis was performed because all patients diagnosed with cancer
during that period had at least five years of follow-up data until
December 31, 2009. For the 2005-2009 period, survival analysis
was carried using the period method24, given that there is no
complete 5-year follow-up for patients, as shown in Figure 5. The
number in each cell indicates the minimum number of years of
follow-up completed by patients at the end of a specific year.
For the 5-year net survival estimates, the Pohar-Perme estimator
was used  25. Life tables of the general population of Cali in one-

Follow up Year
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
1995 1 1-2 2-3 3-4 4-5 5
1996 1 1-2 2-3 3-4 4-5 5
1997 1 1-2 2-3 3-4 4-5 5
1998 1 1-2 2-3 3-4 4-5 5
1999 1 1-2 2-3 3-4 4-5 5

2000 1 1-2 2-3 3-4 4-5 5

2001 Cohort approach 1 1-2 2-3 3-4 4-5 5
2002 1 1-2 2-3 3-4 4-5 5
Diagnosis Year

2003 1 1-2 2-3 3-4 4-5 5

Period approach

2004 1 1-2 2-3 3-4 4-5 5

2005 1 1-2 2-3 3-4 4-5

2006 1 1-2 2-3 3-4
2007 1 1-2 2-3
2008 Cohort approach 1 1-2
2009 Period approach 1

Figure 5. Cali Cancer Population Registry. Monitoring structure for the analysis of survival of cancer cases in permanent residents of Cali during the 1995-2009 interval
with follow-up until 2009-12-31. Three 5-year periods were analyzed: 1995-1999, 2000-2004 and 2005-2009. Cohort approach between 1995-2004 and between 2005-2009.
In contiguous cells the complete tracking of an interval was described. Example: All patients with a diagnosis in 1995 complete one year of follow-up in 1996, except for
those diagnosed in 1995-01-01.

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 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Table 1. International Cancer Survival Standards (ICSS) used for standardizing survival by age according to cancer site. Age classes and
weighting for three types of cancer incidence age patterns.
ICSS-1 ICSS-1*
Group age Weight Group age Weight
15-44 0.07 15-54 0.19
45-54 0.12 55-64 0.23
55-64 0.23 65-74 0.29
65-74 0.29 75-84 0.23
75+ 0.29 85+ 0.06
Total 1   1
ICSS-1*: Prostate (C61)
ICSS-1: Stomach (C16), colorectal (C18-C20), liver (C22), lung (C34), breast (C50), ovary (C53), non-Hodgkin's lymphoma (C82-C85, C96), multiple myeloma
(C90), leukemia (C91-C95)
ICSS-2: Melanoma (C43), cervix (C53), thyroid (C73)
ICSS-3: Hodgkin's lymphoma (C81)
year age group, by sex and for each calendar year from 1995 to
2010, were provided by the Concord-2 study23. Estimates of 5-year
net survival were standardized by age to allow comparisons over
time or with different cancer populations and with different age
distributions. The three main cancer sites with similar incidence
patterns by age were taken into account and the weights of the
International Standard for Survival of Cancer, International
Cancer Survival Standard ICSS 26 (Table 1) were implemented.
Exhaustiveness assessment by death certificate method
To verify the exhaustiveness, the death certificate method
was used  27. The principle is illustrated in  Figure 6. Individual
certificates of general mortality from all causes are received
annually in a structured file in a digital format with information
on causes of death in text and the basic cause codified with ICD-
10  17. We reviewed the causes of death to detect cancer cases
that were not coded as cancer in the basic cause; and a variable
is created to identify cancer cases (ICD-10: C00-C97; D05-D06,
D32-D33, D45-D46, D47.1, D47.3). The initial pairing with the
RPCC database allows to identify the prevalent cases that have
died, the vital status and the date of death are updated. New cases
reported annually through the death certificate are included in the
RPCC database and are identified in a variable such as DCN. These
cases will then be updated when the RPCC data collectors obtain
newer information from the biopsy, the bone marrow aspirate, or
the flow cytometry; the diagnostic method is updated, from death
certificate to diagnosis by morphology. The active and continuous
search of cases excludes some cases of mortality that are not
related to cancer; and which will be used to update, once more,
the diagnostic method that will convert from death certificate
to diagnosis by clinical or by images. Finally, there is a remnant
of cases whose only information came from death certificate
(DCO). The proportion of unregistered cases that remained
alive was estimated with the proportion of cases initiated by the
death certificate (DCI) and the mortality: incidence ratio (M: I).
Exhaustivity = 1−DCI *(1M:I)/(1−DCI)
Results
Indicators of quality of the incidence information
The main quality indicators for some selected cancer sites are
presented in  Table 2. Age was known in 99.4% of patients. The
mortality incidence ratio showed consistent values ​​except for liver
(1.43) and lung (1.02). In these locations, the number of deaths
was greater than the number of cases recorded in the registry.
115
ICSS-2 ICSS-3
Group age Weight Group age Weight
15-44 0.28 15-44 0.6
45-54 0.17 45-54 0.1
55-64 0.21 55-64 0.1
65-74 0.2 65-74 0.1
75+ 0.14 75+ 0.1
  1   1
The percentage of cases with morphological verification (MV)
-histology, cytology, bone marrow aspiration and flow cytometry-,
for all cancer sites was 88.5% ranging between 85-100%, except
in the liver (68.3%) and lung (66.4%). In patients with leukemia,
Hodgkin’s lymphoma and melanoma the MV was 100%.
The percentage of cases with a death certificate only (DCO) varied
between 0-3%, except in the liver (4.5%) and in the lung (6.0%).
In general, for major cancer sites, they had a low percentage of
cases obtained through death certificate only. Another indicator
of quality that is also usually considered is the proportion of
cancer cases that was coded as poorly defined site. Between the
years 2008-2012 these tumors represented 4.6% of new cases of
cancer in men and 5.4% in women.
Quality indicators of survival information
During the 1995-2009 period, 40,354 cases of the selected cancers
were registered, 1.73% occurred in patients under 15 years. In 2.4%
there was no age information and they were excluded from the
analysis. All patients had follow-up and 13.2% of the observations
were censored; this proportion was higher in brain, melanoma,
colorectal and ovarian cancers. In cancers with poor survival:
stomach, lung, liver and pancreas; the censored rate was less
than 10%. In the most frequently diagnosed cancers the censored
percentage was 10.1%, 11.5% and 16.4%; for breast, prostate and
cervix, respectively. In 15.3% of the cases the date of death and the
date of incidence were the same.
Quality indicators of cancer mortality certification
Mortality due to cancer represented 18.0% (23,793 / 132,397) of
the total deaths that occurred in the city during the period 2006-
2015. 0.8% of the cases were not coded as cancer in the basic
cause. All deaths were certified by a physician; the proportion
of poorly defined site (C76-C80, C97) was 5.3% and that of the
uterine cancer not specified (C55) was 0.5%. Only 4 (0.02%) of
the death certificate cases did not have age information. 94.2% of
cancer deaths were well certified.
All patients died from cancer during the 2008-2012 period were
found in the cancer registry database. For recognized sites of
metastasis; liver, lung, bone and brain; the ICD-10 (17) code of
the death certificate was compared with the topographic code of
the ICD-0-311 assigned by the cancer registry. Table 3 shows the
concordance of the two systems to assign the code for each of the
described locations. 45% of the deaths coded as liver cancer in the
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Discharges No Extraction 1. Individual

Registered List Search
Summaries

Yes
Notification No Cancer
Systems TRACED

Update
Linkage
RPCC
There is not Trace to registered cases Cancer Register as
other source (via physician certificate) TRACED appropriate
Yes source
Wait

Different Not
Casa registered
source to TRACED
Death from this source
Registered (DC)
Certificates No Registered as

DCN Cases DCI Cases DCO Cases

Figure 6. Assessing the exhaustiveness. The annual matching between the mortality database and the cancer registry makes it possible to identify new cases notified by
means of the death certificate (DCN). The active and continuous search of the cases updates the most valid basis for the diagnosis and excludes some cases of mortality
that are not cancer (Tracking not cancer). The remaining are the cases initiated by a death certificate (DCI) that would not have been detected by another way. After all the
tracking maneuvers, there remains a residue of cases for which the only evidence of cancer was the death certificate (DCO).

death certificate corresponded to metastasis. In the RPCC there
was evidence (morphological and clinical verification) of having
made the diagnosis of cancer in the patient’s life in a different
primary site. This proportion reached values ​​of 46%, 15% and 10%
for bone, lung and CNS locations.
oncological services were visited, located in medical centers
(64), private clinics (36) and private offices (5). Information was
obtained that identified 2,215 new cases of cancer (27.8%) and
updated 5,750 cases (72.2%) that were already in the database of
the RPCC.

Exhaustiveness assessment by death certificate method Discussion

The 54% of people who died from cancer in Cali during the
2008-2012 period were already included in the RPCC database.
The new cases notified by means of the death certificate (DCN)
corresponded to 46% of the deaths of the period. The proportion
was higher in cancers with high lethality as stomach (45%); and
lower, in patients with breast cancer (12%), cervix (18%), prostate
(14%) and childhood cancer (23%),  Table 4. The exhaustivity
index was greater than 90%, except in cases of prostate cancer.
Periodic survey of oncological services
The last survey conducted in 2014 costed US $ 23,300, where 19
students participated, each one received a bonus, transportation
cost and one payment per survey. During the eight weeks, 107
The Cali cancer registry is the only one registry in low and middle
income countries that has accurately reported the cancer situation
continuously over the last half century. The information is of high
quality and has been included in all eleven volumes of Cancer
Incidence in Five Continents (CI5)21,28-37.
For forty years, RPC-Cali and was the only valid source of
information on the incidence of cancer in Colombia  2. The
National Cancer Institute of Colombia (INC-Col) with the
support of Universidad del Valle, promoted in the first decade of
the 21st century the establishment of RPCs in strategic regions of
the country to increase coverage. Due to this effort, the incidence

Table 2. Cali, Colombia. Indicators of the data quality of the incidence information for both sexes during the period 2008-2012
Cancer site n Age (%) M/I 1-NS MV (%) DCO (%) ICD-10
Stomach 1,810 99.7 0.78 0.83 85.1 3.0 C16
Colorectal 1,827 99.6 0.55 0.59 89.8 1.4 C18-20
Liver 467 99.8 1.43 0.95 68.3 4.5 C22
Lung 1,316 99.9 1.02 0.90 66.4 6.0 C33-34, C38-39
Skin melanoma 324 98.2 0.40 0.34 100.0 0.0 C43
Breast* 2,998 99.5 0.33 0.26 97.0 0.3 C50
Uterine cervix 1,037 99.5 0.45 0.42 94.4 1.2 C53
Ovary 513 100.0 0.59 0.66 87.1 0.6 C56
Prostate 2,937 99.2 0.32 0.17 89.2 2.0 C61
Thyroid 1,066 98.0 0.07 0.11 97.9 0.3 C73
Hodgkin's disease 154 100.0 0.20 0.36 100.0 0.0 C81
Non-Hodgkin lymphoma 1,013 99.9 0.35 0.57 99.6 0.0 C82-C85, C96
Multiple myeloma 298 99.7 0.55 0.77 99.7 0.0 C90
Leukemia 867 99.5 0.67 0.72 100.0 0.0 C91-C95
All sites 23,046 99.4 0.51   88.5 1.7  
M/I: Mortality:incidence ratio
MV: Proportion of cases verified microscopically
DCO: only evidence of death certificate
NS: Net survival
* 26 cases of breast in men are included

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Table 3. Cali, Colombia. Coding concordance for some selected sites between the Cali Population Registry of Cali and the Municipal
Public Health Secretariat. 2008-2012.
Information source Cancer registry
Liver (C22)
Location Kappa 95% CI
Yes No
Yes 341 284 0.638 0.60 0.68
Liver (C22) No 3 1,819
Lung (C33-C34)
Municipal Yes 980 250 0.790 0.75 0.83
Lung (C33-C34) No
Public Health 7 1,210
Secretary Bone (C40-C41)
Yes 50 43 0.671 0.63 0.71
Bone (C40-C41) No 4 2,350
SNC (C70-C72)
SNC (C70-C72) Yes 430 69 0.899 0.50 1.29
No 8 1,940
IC 95%: Interavalo de confianza 95%
Kappa: Concordancia: <0.00: Pobre; 0.00-0.20: Leve; 0.21-0.40: Aceptable; 0.41-0.60: Moderada; 0.61-0.80: Considerable; 0.81-1.00: Casi perfecta

information of the Colombian cities of Pasto, Manizales and
Bucaramanga was added to that of Cali and published since
2012 in CI536, and the four Colombian RPCs participated in the
CONCORD study23, the global program for global surveillance
of cancer survival, led by the London School of Hygiene and
Tropical Medicine.
at the top of the Colombian research system. With specific
projects, it provides solution to epidemiological problems and
complements information gathering activities. The total cost per
case in the RPCC was US $82, which included US $ 25 for fixed-
cost activities, US $ 43 for central variable-cost activities, and US
$ 14 for other activities38.

Currently, the RPC-Cali participates in SURVCAN-3, an initiative
of the IARC to produce reliable and comparable survival statistics
for countries in transition. Due to the great strength of the Cancer
Registry, Cali is the first city in the world to implement the
initiative “C/Can 2025: Challenge of Cities Against Cancer”; an
initiative of the International Union for Cancer Control (UICC)
that seeks to increase the coverage and quality of oncological
care in the cities of more than one million inhabitants of low and
middle income countries.
Success factors of the RPCC
Several factors have contributed to the stability and continuity
over time of the Cali Cancer Registry. The RPCC has standardized
definitions and procedures for the collection, analysis, storage,
validation and dissemination of information. Universidad
del Valle has been the main source of financial and technical
resources. The four directors that the RPCC has had in the 55
years of operation have been academics and researchers of the
Department of Pathology, in charge of coordinating a trained
human resource that belongs to the plant of the Universidad del
Valle. The RPCC is constituted as a research group and ranked
The RPCC has social recognition in the city, thus facilitating
the process of data collection that is made passively and actively
from the various sources of data information. The oncological
care facilities in Cali, include 165 oncology services enabled8  to
offer accurate diagnosis and adequate treatment to 9,000 patients
per year  39. Since its foundation in 1962, the RPCC limited the
registration area to the urban area of ​​Cali and developed a clear
definition of “case”, including only the new cases of cancer
diagnosed in the permanent residents of the city; and excluding
the cases of patients referred to the city for diagnostic and/or
treatment procedures.
To estimate the rates and to construct the life tables for the survival
study, reliable denominators based on population censuses and
projections are required. The DANE facilitated the demographic
structure of the population for the period 1962-2015.
Regulations for the notification of cancer in Colombia.
The Colombian government positioned cancer as a primary
public health problem and established actions for comprehensive
care to reduce morbidity and mortality due to this disease and

Table 4. Population Registry of Cancer of Cali, Colombia. Percentage of registered cases as DCN, DCO, and mortality ratio: incidence;
in selected locations. Period 2008-2012.
DCN DCN/M DCO DCO/M Incidence Mortality DCI DCI/M
Cancer site MI Exhaustiveness
n % n % n n n %
All 5,327 0.46 371 0.03 23,046 11,664 0.51 1,403 0.12 0.87
Stomach 625 0.45 53 0.04 1,810 1,374 0.72 99 0.07 0.97
Colorectal 332 0.34 25 0.03 1,827 987 0.53 68 0.07 0.94
Breast 115 0.12 7 0.01 2,972 941 0.32 32 0.03 0.92
Cervix 81 0.18 11 0.02 1,037 462 0.45 16 0.03 0.96
Prostate 126 0.14 54 0.06 2,937 913 0.31 103 0.11 0.72
Child <15 38 0.23 1 0.01 402 167 0.42 3 0.018 0.97
MI: Mortality:Incidence ratio
DCN: New cases notified annually to the RPCC through the death certificate
DCI: DCN - cases excluded from mortality that are not cance
DCO: New cases in the RPCC whose only evidence of cancer is the death certificate.
exhaustiveness: (1-DCI*(1/M:I))/(1-DCI
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 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
improve the quality of life of cancer patients. Surveillance and
control mechanisms were implemented, and the National Cancer
Information System was organized. The model of care for these
diseases was defined in the Ten-Year Plan for Cancer Control
in Colombia 2012-202140, and the axis of this strategic plan is
surveillance, situational analysis and research. The Ministry
of Health and Protection of Colombia (Ministerio de Salud y
Protección Social) regulated the basic data that health insurers
and health entities must report on the oncological services
provided, whether they are promotion, prevention, diagnosis,
treatment or rehabilitation (RIPS). For the management of
information on public health, the Public Health Surveillance
System (SIVIGILA) was regulated for the surveillance of breast
cancer, cervical cancer and childhood cancer. The objective is to
determine the opportunity at the beginning of the treatment of
confirmed cases and to estimate the frequency of cases detected
at different stages. Since 2014, health insurers (EPS) must
report cancer information to the High Cost Account (CAC), a
non-governmental organization that was created to guide the
management of health risk and ensure the management of the
disease of the people affected.
Strengths of the RPCC: Quality indices during the period 2008-
2012
The value of a cancer registry depends greatly on the quality of the
data and on the quality control procedures in force 4. The RPC-
Cali takes four dimensions into account to determine the quality
indicators of the data collected: comparability, validity, timeliness
and exhaustiveness.
Comparability
The RPCC uses standard methods to make the information
comparable to other regions of the country and the world. The
neoplasms are coded with the ICD-O-3 for adults11 and the ICCC-
3 for children 12. For date of incidence, the guidelines of the ENCR
(13) are followed and the IARC guidelines for the classification of
multiple primary tumors were used14.
Validity
The main and most reliable sources of data for the cancer registry
are the histopathology reports; but they are not enough to
guarantee clarity, such as poorly accessible tumors: those of the
CNS, pancreas, lung, retroperitoneum and others; the basis of the
diagnosis can be imaging studies, clinical examination and DCO.
The percentage of RPC-Cali cases with a morphologically verified
diagnosis (MV%) was 88.5%, similar to other RPC-Colombians
and RPC-Latin American; and inferior to the majority of PRC-
Europeans and North American RPCCs (90% -95%)37. Africa
has the two contrasts (53.9% Uganda: Kyandono Country, 97.8%
Algeria: Sétif)37. In low and middle income countries, a large
proportion of cases diagnosed through the pathology service may
suggest deficiencies in the search for cases and, therefore, evidence
of incomplete registration.
In the RPC-Cali, the percentage of cases known only by death
certificate (DCO%) was 1.7%; the lowest of all the RPC-Latin
American; and like most RPC-North American and RPC-
European37. Some RPCs in Africa and Latin American have DCO%
greater than 10%; which indicate poor case detection and poor
quality, because death certificates do not provide information on
118
the morphology of the tumor. A high proportion of new cases of
cancer based on a clinical diagnosis has the same interpretation.
Exhaustiveness
The incidence rates have been stable over time and the expected
values ​​are comparable with those reported by cancer registries
that serve similar populations such as Quito (192.8 person-years
and 198.9 person-years in men and women, respectively) and
Costa Rica (173.9 person-years and 167.0 person-years in men
and women, respectively)37.
The collaborative work with the SSPM of Cali facilitates access
to information on general mortality and cancer; and allows us to
have an independent source of verification of new cases of cancer.
Cancer deaths were well certified at about 94.2%. The M:I ratio
for all cancer sites during the period 2008-2012 was 51%; similar
to that of other RPC-Latin American (range, 38.3% to 68%)36 and
higher than that reported by the United States (34.8% in men, and
36% in women)36 through the SEER (Surveillance, Epidemiology,
and End Results Program). In many Latin American countries,
the M:I ratio is greater than one in tumors with high fatality such
as pancreas, liver, esophagus. Fatality of these cancers are due to
lack of complete information and/or lack of diagnosis when the
patient was alive.
The exhaustivity index was 87% (method of death certificates IE-
CD) and in the cancers prioritized by the PNDC it was greater
than 90%, except in cases of prostate cancer (72%). This RPC-Cali
index is higher than that reported by other international cancer
registers (82.8% in Japan, Miyagi, 80.4% in Germany, Münster
and 65.6% in the United Kingdom)41.
The method depends on the availability of relatively good quality
certificates, which mention the cause of death (completely and
accurately) in the area covered by the cancer registry. This method
has not been applied in other RPC-Latin American countries.
Opportunity
The statistics of the cancer situation in Cali are public access after
36 months following the year of diagnosis. Data is also available
on the RPPC portal http://rpcc.univalle.edu.co. This information
describes 50 years of incidence (1962-2012), 30 years of mortality
(1984-2014) and 15 years of survival (1995-2009).
Limitations
The data of each service in each institution are handled
autonomously and independently. because the information is
managed on different platforms, generating duplication of data,
data transfer difficulties and a decrease in the quality and integrity
of the information.
The Colombian oncology services periodically notify to different
dependencies of the ministry of health (SIVIGILA, RIPS, CAC).
These legacy systems are mostly local applications that lack
interoperability for proper data management. Institutions begin
to perceive notification as a burden and relegate them and
deprioritize data transfer to the cancer registry. This complexity
is a risk factor to guarantee completeness in the collection
of information. Consequently, there are great possibilities of
underestimating the cancer risk in the population. It is urgent
to modify the current Ministry of Health regulations so that the
 García LS/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
RPC-Colombians are incorporated into the cancer information
system with an adequate budget allocation.
Future challenges
The implementation of standards and transfer mechanism,
shared information flows and adoption of tools are priorities
to communicate effectively with different information systems
in the city of Cali. Also set public policies that facilitate the
implementation of these solutions. And then, the creation of
an interinstitutional data warehouse is essential to provide key
support for making decisions both public at the population
level and administrative at the clinical level. The main objective
of this implementation is to guarantee quality information for
knowledge management proposes.
Acknowledgements:
To all patients and to all oncology care services in Cali. This
research was funded and carried out by Universidad del Valle.
Funding:
COLCIENCIAS: 1106-40820552
COLCIENCIAS Young researchers and innovators program:
No.463-2008
COLCIENCIAS Young researchers and innovators program:
No.645-2014
National Institute of Cancerology No.941-2006
National Institute of Cancerology No.C0026-2009
National Institute of Cancerology No.0511-2011
National Institute of Cancerology No.0214-2012
National Institute of Cancerology No.0378-2014
Univalle-Vandervilt University-NIH-USA (Prime Award No.2
P01 CA028842-24, Subaward No. VUMC3239, 2009-2015)
Universidad del Valle, Bristol Myer-Squibb Laboratory (GRANT
COL 048-2008, COL 039-2009)
Conflict of interests:
None
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 Cendales R/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Technical report

Quality of death certification in Colombia

Calidad del certificado de defunción en Colombia

Ricardo Cendales*, Constanza Pardo*

Grupo de Vigilancia Epidemiológica del Cáncer, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia.

Cendales R, Pardo C. Colombia death certificate quality. Colomb Med (Cali). 2018; 49(1):121-127. doi: 10.25100/cm.v49i1.3155

© 2018 Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution and reproduction in any medium, provided that the original author and the source are credited. e Creative Commons Attribution License, which permits
unrestricted use, distribution and reproduction in any medium, provided that the original author and the source are credited.

Article history: Abstract Resumen

Objective: To evaluate overall quality of death certification and quality of
Received: 7 June 2017
Revised: 19 February 2018 cancer mortality certification in Colombia.
Accepted: 1 March 2018 Methods: Classic validity indexes were described through simple
percentages for each department and five cities: Bogotá, Cali, Manizales,
Keywords: Pasto and Bucaramanga. A factorial analysis of principal components
Data collection, vital statistics, was performed in order to identify non-evident relationships.
cause of death, developing
Results: 984,159 deaths were analyzed, 164,542 corresponding to cancer
countries, data quality, health
information systems. deaths. 93.7% of the overall mortality was properly certified. Most errors
were due to signs, symptoms and ill-defined conditions. 92.8% of the
Palabras clave: cancer deaths were properly certified. Ill-defined cancers site certification
Recolección de datos, prevailed as the most frequent cause of error.
estadísticas vitales, causas de
Conclusions: Colombia showed improvement in all indicators of quality
muerte, países en desarrollo,
calidad del dato, sistemas de certification. Given the high performance of quality indicators for overall
información en salud. death and cancer death certification, it is considered that mortality data
can be used in the cancer incidence estimation process.
Objetivo: Evaluar la calidad de la certificación de la muerte general y
por cáncer en Colombia.
Métodos: Se describieron indicadores de validez para cada departamento
y las ciudades de Bogotá, Cali, Manizales, Pasto y Bucaramanga. Se
realizó un análisis factorial de componentes principales con el fin de
identificar relaciones no evidentes.
Resultados: Se analizaron 984,159 defunciones, dentro de las cuales
había 164,542 muertes por cáncer. El 93.7% de la mortalidad general
estaba bien certificada. Los errores predominantes fueron signos,
síntomas y afecciones mal definidas. El 92.8% de la mortalidad por
cáncer estaba bien certificada. Los errores predominantes fueron
cánceres de sitio mal definido.
Conclusiones: Los indicadores de calidad de certificación en Colombia
mejoraron. Ante el buen comportamiento de los indicadores de calidad
de la certificación de la muerte general y por cáncer, se considera que
esta es un insumo válido para la estimación de incidencia de cáncer.

Corresponding author:
Constanza Pardo, Grupo de Vigilancia Epidemiológica del Cáncer, Instituto
Nacional de Cancerología, Calle 1 No. 9-85, Teléfono y fax 4320160 ext. 4806,
Bogotá D.C., Colombia. Correo electrónico: cpardo@cancer.gov.co
121
 Cendales R/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
Introduction
The measurement and monitoring of the quality of mortality
information is a very important component in the evaluation
of health information systems in each country1. Mortality is
a fundamental input for the analysis of situations in health,
monitoring results of public health programs, and planning
needs in health services2; while also being an essential input for
estimating incidents of cancer3,4.
In Colombia, around 12% of the population is covered by a group
of cancer population registries (RPC, for its acronym in Spanish):
Cali, Pasto, Bucaramanga, Manizales and Barranquilla5. The
RPC information and the available national mortality data allow
for national incidence estimates for cancer. On a first analysis,
the National Cancer Institute (INC, for its acronym in Spanish)
evaluated the quality of the certification of general mortality
and cancer mortality as part of the validation process of the
information sources6. This report reviews the progress of the
quality of the certification of general mortality and cancer based
on the official information of the national vital statistics registry
system of the National Administrative Department of Statistics
(DANE, for its acronym in Spanish). This information is necessary
for the estimation of cancer incidences 2007-20117 and other types
of analysis with mortality8-10.
This publication presents the evaluation of the quality of the
certification of death in Colombia during the period 2007-2011,
according to the province of occurrence; it also presents the results
for the capital district (Bogotá) and the four cities in which the
cancer population registries operate.
Materials and Methods
A descriptive study of the quality of mortality information was
made from death certificates in Colombia. The results are presented
disaggregated according to the province or city where the death
occurred. For the provinces that have municipalities with RPC, the
data of these municipalities is excluded to avoid redundancy. Thirty
two provinces were included, the capital district (Bogotá) and the
cities of Manizales, Pasto, Cali and Bucaramanga (which comprise
the towns of Bucaramanga, Floridablanca, Girón and Piedecuesta)
that have active cancer population registries, which are endorsed
by the International Agency for Research in Cancer (IARC, for its
acronym in English)  11, with a coverage of 12% of the population
that represents the country. The source of information is the official
DANE mortality database for the five-year period 2007-2011.
Statistical methods
The description of the quality of the certification was made through
simple percentages. Each aspect related to the lack of quality in the
information was considered only once; for example, if the death
was not certified by a physician, but it also had another certification
problem, this record was not counted twice but only once as a
record that had faults in its certification quality. The results are
presented in a logical order in such a way that those that appear
in the first column of the tables correspond to the first reason of
lack of quality; those that appear in the second column correspond
to records that have other faults different from the first; and so on
(Tables 1 and ​2).
122
Indicators for the general evaluation of information quality
The International Classification of Diseases (ICD-10) was used to
group and codify the causes of death.
The following indicators were constructed: deaths from cancer
certified as primary non-established, from poorly specified
sites, or as a consequence of metastatic tumors (C76-C80, C97);
cardiovascular deaths of ill-defined etiology (I47.2, I49.0, I46,
I50, I51.4, I51.5, I51.6, I51.9, I70.9); injuries of indeterminate
intentionality (Y10-Y34, Y87.2); deaths that were recorded as signs,
symptoms and ill-defined conditions (R00-R99); deaths without
sex information; deaths that were not certified by physicians; and
deaths that don’t have any cause of error in the certification.
Indicators in the evaluation of quality of information on cancer
mortality
The following indicators were constructed: deaths from uterine
cancer of unspecified site (C55); deaths from cancer of non-stated
primary, from poorly specified sites, or as a consequence of a
metastatic tumor without an established primary (C76-C80, C97);
deaths from cancer without age information; cancer deaths that
were not certified by a physician; and well-certified cancer deaths.
Analysis plan
In order to detect a possible underlying relationship structure, a
factorial analysis of the principal components was carried out, both
for the analysis of the certification quality of general mortality and
for the analysis of the certification of cancer mortality; the Kaiser-
Meyer-Olkin statistic and the Bartlett sphericity test were used to
identify if there was an underlying relationship structure 12. Those
factors that did not fit with the proposed solution of major factors
were excluded from the analysis; the number of factors was selected
with the help of graphic analysis; in those cases in which it was
considered appropriate, an orthogonal rotation was made using the
analysis of principal components as the extraction method, and the
varimax with Kaiser normalization as a rotation method based on
graphic analysis.
Results
In the evaluation of the quality of the certification of general
death for Colombia, there were 984,159 deaths considered for the
five-year period 2007-2011. For general mortality in the area of​​
influence of the population registries of cancer in Bucaramanga,
Cali, Manizales and Pasto, 138,716 deaths were analyzed (14.1% of
the national mortality).
Quality indicators of certification of death due to general causes
The national percentage of duly certified deaths was 93.7%. The
indicators that most affected the quality of the certification were:
signs, symptoms, ill-defined conditions (2.0%) and ill-defined
cardiovascular deaths (1.9%). Ten provinces had a percentage of
deaths without errors in the certification lower than 90.1%, and they
represented only 6.6% of the deaths in the country. Vaupés was the
province with the lowest indicators in certification, with 77.2%. The
quality of the general certification for deaths without errors ranged
from 92.3% to 96.4% for the cities of Cali, Manizales, Bucaramanga
and Pasto. The city of Bucaramanga showed a lower proportion in its
indicators with respect to the other cities (Table 1).
 Cendales R/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
1.0
Ill-defined Cardiovascular Diseases
0.5 Ill-defined Cancer
Component 2
0.0
Symptom Injuries
-0.5
Non medical
-1.0
-1.0 -0.5 0.0
Component 1
Figure 1. Results of the analysis of principal components in the general
evaluation of the quality of the certification (rotated graph), Colombia, 2007-
2011. Extraction method: Principal component analysis and Rotation method:
Varimax standardization with Kayser.
The analysis of principal components showed two that can explain
the lack of quality: the first one is related to the lack of certification
by a physician and the consequent inadequate certification of
death, either as a sign, symptom or ill-defined condition or as an
undetermined intentionality injury (Amazonas, Cauca, Guainía,
Vaupés); the second component has to do with the provinces in
which, despite having certification by a physician, there are errors in
the certification of cancer deaths and deaths due to cardiovascular
causes (Santander, Norte de Santander, Boyacá, Sucre) (Table
1 and Fig. 1).
Quality indicators of cancer death certification
Were analyzed 164,542 deaths. The percentage of cancer deaths
duly certified was 92.8%. The indicators that most affected the
quality of the certification were deaths due to poorly defined cancer
sites (6.1%) and deaths from ill-defined site uterine cancer (0.9%).
The analysis disaggregated by provinces showed 10 provinces with
a percentage of deaths duly certified that were lower than 91.6%,
which represented 9% of the total deaths due to cancer; Amazonas
was the province that had the lowest indicators in the quality of
cancer mortality certification (Table 2). In the analysis by cities,
Bucaramanga, Cali, Manizales and Pasto, showed a range of 92.8%
to 94.5% for the certification of deaths. The lowest quality was
observed in the indicators of deaths due to unspecified uterine
cancer and cancer from poorly defined sites, mainly in Manizales
and Bucaramanga. The analysis of principal components only
identified a principal component shared by all the provinces, so a
reduction in the dimensions could not be made (Figure 2).
Discussion
Colombia is among the countries with medium-high status
according to the quality of certification of the cause of death  13.
Although there is a broad framework for evaluating the quality of
certification of general mortality, the components contemplated
in this document do not differ from those considered for the
period 2002-2006; and we included the classic indicators of quality
123
1.0 Non medical
Sex Unk
0.5
Component 2
Ill-defined Uterus
0.0
Ill-defined site
Age Unk
-0.5
-1.0
0.5 1.0 -1.0 -0.5 0.0 0.5 1.0
Component 1
Figure 2. Results of the analysis of principal components in the evaluation of
the quality of the certification by cancer (rotated graph), Colombia, 2007-2011.
Extraction method: Principal component analysis and Rotation method: Varimax
standardization with Kayser.
for general mortality: proportions of deaths certified by a non-
physician, without age, of unknown or nonspecific causes 14-16, and
the indicators of cancer mortality quality: percentages of deaths
due to poorly defined cancer site and deaths due to uterine cancer
from non-specific sites17,18.
This report confirms that Colombia is classified by the World
Health Organization (WHO) -IARC as a class 2 country, with an
average quality of mortality certification. According to this index,
the countries classified as medium quality have a percentage of
completeness that is between 70 and 90%; or have a percentage
of completeness greater than 90% but with a percentage of deaths
certified as signs, symptoms and ill-defined conditions that are
between 10 and 20%; or have an  exhaustivity  (thoroughness)
greater than 90%, with less than 10% of deaths certified as signs,
symptoms and ill-defined conditions, but do not use codes of an
international classification of diseases13,19. It is possible that the
classification of Colombia rises to that of a country with high
quality in the certification of mortality since we have a percentage
of deaths certified as signs, symptoms and ill-defined conditions
that is less than 10%, and the last WHO’s coverage report of death
reports that Colombia went from having coverage of 79.9% in the
period 1990-1994 to 88.1% in 1995-1999, 93.1% in the period
2000-2004, and 98.5% in 200920.
An improvement in all the certification quality indicators in
Colombia was demonstrated, both globally and in the analysis
disaggregated by provinces and some cities. The quality of the
certification for general death was good with a percentage of deaths
duly certified (93.7%), which improved the figure observed for the
period 2002-2006 (92.8%). The results of the evaluation of the
certification quality of cancer deaths (92.8%) also exceeded 91.5%
that had been reported for this same period. Vaupés remained
the province with the lowest indicators of the overall quality of
certification, although its figures improved from 66.9% to 76.2%.
The signs, symptoms and ill-defined conditions went from 1.5%
to 2.0%.
 Cendales R/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)

Table 1. General evaluation of the quality of the certification according to the place of occurrence of the death, Colombia, 2007-2011.
Signs,
Deaths from Deaths that Deaths
Ill-defined Injuries of symptoms Deaths Deaths
Geographic cancer of were not without Total
cardiovascular undetermined and ill- without sex without age
ordering non-stated certified by errors in deaths
deaths intentionality defined information information
primary a physician certification
conditions
Amazonas* 0.4 1.1 2.8 7.2 0.0 0.0 7.3 81.2 848
Antioquia* 1.2 1.4 0.9 1.5 0.0 0.0 0.0 94.9 148,653
Arauca* 0.5 1.7 1.1 1.7 0.0 0.0 0.3 94.7 4,494
Atlántico* 0.9 2.0 0.5 1.9 0.0 0.0 0.0 94.6 46,182
Bogotá D.C.** 1.2 1.4 1.6 2.7 0.0 0.0 0.0 93.1 159,432
Bolivar* 1.2 2.4 0.8 2.9 0.0 0.0 0.4 92.3 29,089
Boyacá* 0.8 3.1 1.5 1.4 0.0 0.0 0.3 92.8 29,704
Caldas* 1.0 2.2 0.8 1.2 0.1 0.0 0.1 94.7 12,166
Manizales§ 1.2 1.1 0.4 0.9 0.0 0.0 0.0 96.4 15,651
Caquetá* 1.0 2.2 3.2 3.6 0.0 0.0 0.2 89.7 8,121
Casanare* 1.2 2.9 3.5 2.8 0.0 0.0 0.3 89.4 4,799
Cauca* 0.8 1.8 1.5 3.6 0.0 0.0 3.9 88.4 22,658
Cesar* 0.9 2.3 1.0 2.7 0.0 0.0 0.2 92.9 17,480
Chocó* 0.6 1.8 3.0 4.9 0.0 0.0 2.1 87.6 5,381
Córdoba* 0.6 2.4 0.7 2.1 0.0 0.0 0.8 93.3 26,801
Cundina-
0.8 2.6 1.4 3.0 0.0 0.0 0.0 92.1 43,956
marca*
Guainía* 0.0 2.3 1.4 1.4 0.0 0.0 7.6 87.3 353
Guajira* 0.5 1.8 1.0 2.2 0.1 0.0 0.8 93.6 7,227
Guaviare* 0.5 1.3 3.4 3.3 0.4 0.0 0.1 91.0 1,334
Huila* 1.1 1.8 1.5 2.1 0.0 0.0 0.2 93.3 25,036
Magdalena* 0.8 2.3 0.7 2.1 0.0 0.0 0.4 93.6 21,732
Meta* 0.9 1.3 1.2 1.3 0.0 0.0 0.0 95.1 20,611
Nariño* 0.6 2.4 1.9 3.8 0.0 0.0 0.9 90.4 16,746
Pasto¤ 0.9 1.6 0.9 0.8 0.0 0.0 0.0 95.8 14,671
N. Santander* 1.0 4.7 0.9 2.5 0.0 0.0 0.2 90.8 31,768
Putumayo* 0.4 1.2 4.7 2.1 0.1 0.0 1.7 89.8 3,572
Quindío* 1.2 1.4 0.2 0.4 0.0 0.0 0.0 96.7 16,577
Risaralda* 1.2 1.4 0.6 1.3 0.0 0.0 0.0 95.5 27,529
San Andrés* 0.3 2.5 0.2 0.9 0.0 0.0 0.1 95.9 952
Santander* 0.8 3.5 1.4 2.9 0.1 0.0 1.1 90.2 17,838
Bucara-
1.2 2.4 0.4 3.2 0.0 0.0 0.4 92.3 30,725
manga†
Sucre* 0.9 3.1 0.6 1.7 0.0 0.0 0.5 93.2 13,360
Tolima* 0.7 1.3 0.7 0.9 0.0 0.0 0.2 96.2 35,803
Valle* 0.9 1.6 1.0 2.0 0.0 0.0 0.2 94.3 44,184
Cali¤ 1.1 1.2 0.7 0.7 0.0 0.0 0.0 96.4 77,669
Vaupés* 0.0 0.8 3.8 3.2 0.0 0.0 15.0 77.2 474
Vichada* 0.2 2.4 2.9 3.1 0.7 0.0 1.0 89.7 583
Colombia 1.0 1.9 1.1 2.0 0.0 0.0 0.3 93.7 984,159
‡ The geographical order of the country is defined in regions (two or more provinces),
* provinces (several municipalities), followed by special districts
**, § municipalities and metropolitan areas
† (two or more municipalities).
† Metropolitan area of Bucaramanga (Bucaramanga, Floridablanca, Girón, Piedecuesta)

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Tabla 2. Evaluation of the quality of the certification by cancer according to the place of occurrence of the death, Colombia, 2007-2011.
Deaths from Deaths from Deaths from Deaths from cancer
Geographic Duly certified Total deaths
unspecified ill-defined cancer without that were not certified
ordering ‡ deaths from cancer from cancer
uterine cancer cancer site age information by a physician
Amazonas* 1.3 3.9 0.0 7.8 87.0 77
Antioquia* 0.7 6.4 0.0 0.0 92.9 27,411
Arauca* 1.6 4.3 0.0 0.2 93.9 507
Atlántico* 1.1 5.6 0.0 0.0 93.3 7,782
Bogotá D.C.** 0.6 5.8 0.0 0.0 93.6 33,332
Bolívar* 1.0 7.2 0.0 0.2 91.6 4,682
Boyacá* 1.0 6.2 0.0 0.1 92.7 4,024
Caldas* 0.9 6.7 0.0 0.0 92.4 1,876
Manizales¤ 0.4 6.4 0.0 0.0 93.2 3,000
Caquetá* 1.8 8.4 0.0 0.3 89.5 998
Casanare* 2.0 9.2 0.0 0.0 88.8 609
Cauca* 0.9 5.7 0.0 4.0 89.4 3,387
Cesar* 1.1 6.9 0.0 0.0 92.0 2,383
Chocó* 2.0 7.5 0.0 2.0 88.4 441
Córdoba* 1.6 4.7 0.0 1.1 92.6 3,321
Cundinamarca* 1.3 6.3 0.0 0.0 92.4 5,713
Guainía* 0.0 0.0 0.0 0.0 100.0 15
Guajira* 2.6 4.8 0.0 1.6 91.0 765
Guaviare* 3.1 7.2 0.0 0.0 89.7 97
Huila* 0.5 6.8 0.0 0.2 92.5 4,010
Magdalena* 2.3 5.6 0.0 0.5 91.6 3,043
Meta* 0.9 6.4 0.0 0.0 92.7 2,957
Nariño* 1.0 4.8 0.0 0.7 93.5 2,105
Pasto¤ 0.4 5.0 0.0 0.0 94.5 2,617
N. Santander* 1.3 6.5 0.0 0.1 92.1 4,881
Putumayo* 1.7 4.2 0.0 1.1 92.9 353
Quindío* 1.0 6.2 0.0 0.0 92.7 3,209
Risaralda* 0.7 6.9 0.0 0.0 92.4 4,946
San Andrés* 1.6 2.4 0.0 0.0 96.1 127
Santander* 1.3 7.1 0.0 1.1 90.5 1,947
Bucaramanga† 0.5 6.3 0.0 0.4 92.8 5,957
Sucre* 1.3 6.6 0.0 0.8 91.4 1,857
Tolima* 1.2 4.8 0.0 0.1 93.9 5,320
Valle* 1.5 6.3 0.0 0.1 92.2 6,546
Cali¤ 0.5 5.9 0.0 0.0 93.7 14,205
Vaupés* 0.0 0.0 0.0 0.0 100.0 16
Vichada* 0.0 3.8 0.0 3.8 92.3 26
Colombia 0.9 6.1 0.0 0.2 92.8 164,542
‡ The geographic ordering of the country is defined in regions (two or more provinces), provinces
* (set of several municipalities), followed by special districts
**, municipalities¤ and metropolitan areas
† (two or more municipalities).
† Metropolitan Area of Bucaramanga (Bucaramanga, Floridablanca, Girón, Piedecuesta)

Given the good performance of the quality indicators in these two
aspects, it was found that mortality in Colombia as an input for
the estimation of incident cases of cancer is valid, and it does not
require adjustments for under-registration or correction for age,
sex or undefined causes of death; then, in total for the period, it was
only necessary to redistribute 101 deaths without sex information,
1,180 deaths without age information, 2,800 deaths not certified by
physician and 19,937 deaths due to ill-defined causes among a total
of 921,967 deaths without errors in certification.
For the specific case of cancer deaths, 1,452 deaths from ill-
defined site uterine cancer (0.9% of total cancer deaths) should
be redistributed according to standard methodologies; there
would only remain 45 deaths by cancer without age (0.03%) to
redistribute; 347 deaths by cancer not certified by physician (0.2%);
125
and 9,986 deaths by cancer of ill-defined site (6.1%); of a total of
152,753 deaths from well-certified cancer.
In the cities which have a working population registry of cancer,
the indicators were substantially better than in the rest of their
provinces, and they were similar or exceeded the national average
(Manizales 96.4%, Pasto 95.8% and Cali 96.4%), with the exception
of Bucaramanga (92.3%). In the specific case of quality in the
certification of cancer mortality, the indicators of the cities were
also better than in the rest of their provinces (Manizales 93.2%,
Pasto 94.5%, Bucaramanga 92.8%, Cali 93.7%), so it is considered
that the information of general death and death from cancer in
these areas is valid and serves as an input for the estimation of the
mortality incidence ratio necessary for the estimation of incident
cases of cancer. It should be noted that there is a higher proportion
 Cendales R/et al/Colombia Médica - Vol. 49 Nº1 2018 (Ene-Mar)
of deaths in these cities than in the rest of the municipalities of
their respective provinces.
A recommendation for cities with cancer population registries
would be that in the future, an analysis be performed in which
the information about the diagnosis of cancer be crossed with the
cause of death by cancer, in order to go deeper into the quality of
the specific cause of cancer. However, this requires permission to
cross databases with the identifier, which is not possible to perform
at the present time. This particular issue is a call to the health
authorities to allow these crossings with the different health related
information registries.
This analysis was made in accordance with the site of occurrence
of death; however, the analysis of mortality and the calculation
of the mortality incidence ratio are made according to the place
of residence of the deceased, so the quality of the certification
described here may be slightly different from that observed in the
analysis made in accordance with the place of habitual residence.
Phillips et al. , proposed a new methodology to establish the
21
overall performance of the vital statistics system (SEV, for its
acronym in Spanish) in each country, with the inclusion of six
complementary dimensions with their respective indicators, a
methodology that seeks to obtain reliable mortality information
and monitor changes in time. In a second publication,  Phillips
et al  defines the SEV performance index by ranges and for five
categories (very low, <0.25, low, 0.25-0.49, medium, 0.50-0.69, high,
0.70-0.84, very high, ≥0.85). In this study, Colombia evaluated with
the vital statistics information of 2008, presented an index of 82.5,
with a high quality range22. In future work, the application of these
alternative estimation methods will be explored, according to the
available information on mortality in Colombia.
Conclusion
Certification quality indicators in Colombia improved for the
studied period. Given the good performance of the quality
indicators of both the certification of general death and cancer, it
is considered that this is a valid input for the estimation of cancer
incidence.
Acknowledgements:
The authors are grateful for the financial support of this work,
which was carried out with resources from the National Cancer
Institute, Cancer Epidemiological Surveillance Program.
Conflict of interest
Nothing
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 Ramirez-Barbosa P/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Technical report

Cancer risk management in Colombia, 2016

Gestión del riesgo de cáncer en Colombia, 2016

Paula Ramirez-Barbosa, Lizbeth Acuña Merchan

Cuenta de Alto Costo- Fondo Colombiano de Enfermedades de Alto Costo. Ministerio de Salud y Proteccion Social, Bogota, Colombia

Ramirez-Barbosa P, Acuña LA. Cancer risk management in Colombia, 2016. Colomb Med (Cali). 2018; 49(1): 128-136 DOI: 10.25100/cm.v49i1.3882

© 2018. Universidad del Valle. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

Article history: Abstract Resumen

Recibido: 13 January 2018
Revisado: 25 February 2018
Aceptado: 20 March 2018
Keywords:
Cancer, health records,
quality indicators, health care
Palabras clave:
Cáncer, registros de salud,
indicadores de calidad
Objective: To describe the outcomes of risk management indicators
for five types of cancer in population that is affiliated to the General
System of Social Security in Health, in six cities of Colombia.
Methods: Based on the data from the administrative cancer registry
for the period 2016, the High Cost Disease Fund (CAC in Spanish) as
a technical organization of the Colombian health system, processed
and analyzed the data for the calculation of risk management
indicators established in consensus based on the evidence found in
six cities
Results: There is a diversity in the indicators results found among
the different cities, evidencing strengths and weaknesses in each of
them for the different types of cancer. From the set of indicators,
those with the best results presented are related to the greater
detection of cancer in early stages or in situ, as well as a decrease
in mortality, especially in colorectal and in gastric cancer. Most
indicators in gastric cancer showed optimal results. Important
measurements such as the opportunity for diagnosis and treatment
are below the proposed standard for most types in all the six cities.
Conclusions: The descriptive analysis of cancer risk management
indicators shows certain weaknesses in the quality and timeliness
of the care of cancer patients, the standards agreed upon in the
consensus with the different actors of the system are not being
reached, situation which may be due to a reality of problems of the
Colombian health system, as well as deficiencies in the quality of the
report to the CAC.
Objetivo: Describir los resultados de los indicadores de gestión del
riesgo para cinco cánceres en la población afiliada al Sistema General
de Seguridad Social en Salud en Colombia en ciudades que tienen re-
gistros de cáncer.
Metodos: La Cuenta de Alto Costo (CAC) procesó y analizó la in-
formación del registro administrativo nacional de cáncer del periodo
2016 en Cali, Pasto, Bucaramanga, Manizales, Barranquilla y Mede-
llín; para calcular los indicadores de gestión del riesgo establecidos en
el consenso basado en la evidencia para la atención en cáncer.
Resultados: Existe diversidad en los resultados de los indicadores
entre las diferentes ciudades, evidenciando fortalezas y debilidades
en cada una de ellas y para los diferentes tipos de cáncer. Los indica-
dores que mejores resultados presentaron se relacionan con la mayor
detección del cáncer en estadios tempranos, así como disminución
de la mortalidad, especialmente en cáncer de colorrectal y en cáncer
gástrico. El cáncer gástrico fue aquel que mayor cantidad de indicado-
res obtuvieron resultados óptimos. Mediciones importantes como la
oportunidad de diagnóstico y de tratamiento se encuentran por de-
bajo del estándar propuesto para la mayoría de los tipos de cáncer y
de las ciudades.
Conclusiones:
Se evidencia ciertas debilidades en la calidad y la oportunidad de la
atención oncológica, no se están cumpliendo los estándares acordados
en los consensos con los diferentes actores del sistema: puede deber-
se a una realidad de problemas del sistema de salud colombiano, así
como a la necesidad de fortalecer la calidad del reporte por parte de
las entidades a la CAC.

Corresponding author:
Lizbeth Acuña. Cuenta de Alto Costo- Fondo Colombiano de Enfermedades de Alto
Costo. Ministerio de Salud y Proteccion Social, Bogota, Colombia. Carrera 45 N° 103-
34 Oficina 802, Tel. +57 1 6021820, E-mail: l.acuna@encuestadealtocosto.org

128
 Ramirez-Barbosa P/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Introduction
Cancer is a public health problem in Colombia and the world,
which requires decisive interventions to confront and contain
it. For this reason, different strategies and policies have been
developed in different countries and must be based not only on
clinical but also on epidemiological knowledge of cancer, which
must also be tied to the administrative actions that are carried out
at the health insurance level. In order to accomplish this, the way
to know and monitor these actions is through the measurement of
indicators that account for the quality of health care1,2.
In Colombia, information related to cancer has taken great
importance over the years and the country works to obtain
sufficient, real and accurate information with the objective
of analyzing and addressing it to the processes, evidencing
strengths and weaknesses within the health system for the
formulation of strategies, programs and policies that define
corrective interventions. To achieve this purpose, the Ministry
of Health and Social Protection of Colombia (MSPS in Spanish)
through Resolution 4496 of 2012 organizes the National Cancer
Information System (SINCan)3, in which the High Cost Diseases
Fund (CAC in spanish) is part of these information sources,
analyzing data related to insurance and the provision of services
to cancer patients in the country. Similarly, the MSPS-Colombia
with Resolution 0247 of 2014, establishes the report for the
registration of cancer patients where the High Cost Diseases Fund
is responsible for collecting and consolidating the information
that the healthcare payer, including those of the exception regime
and the public institutions, private, and mixed health service
providers, as well as the departmental, district and municipal
health authorities, are mandated to report4.
Therefore, Colombia has a national administrative registry in
cancer (RANC in Spanish) since 2014, with clinical, administrative,
sociodemographic and cost components which, since 2015,
have been audited to guarantee the quality of the information
as a complement to other sources of information. Based on
this information, in 2016 the High Cost Diseases Fund began
the construction and development of processes to standardize
measurements in the cancer care process through consensus
based on evidence for the formulation of indicators that measure
the management conducted by insurers and providers on people
with cancer in the country.
Likewise, another source of information is population-based
cancer registries (RCBP in Spanish) in six cities of the country that
collect and classify new cases of cancer in permanent residents of
Cali, Pasto, Bucaramanga, Manizales, Barranquilla and Medellin.
They are members of the International Association of Cancer
Registries (IACR) and have disseminated information on incidence
and survival in Cancer Incidence in Five Continents5  and in the
CONCORD study6 . The objective of this paper is to describe the
results of risk management indicators for five types of cancer
(stomach, colorectal, breast, cervix and prostate) in the population
that is affiliated with the Colombian General System of Social
Security in Health (SGSSS in Spanish) in the six cities of Colombia
that have RCBP.
129
Materials and Methods
The High Cost Diseases Fund, is a technical body of the General
System of Social Security in Health of Colombia with the mission
of Promoting risk management, the generation of health outcomes
and knowledge management, through the articulation of different
SGSSS actors to decrease the trend of High Cost events, stabilize
the variability in their management, ensure technical-scientific
quality and reduce the impact of the current disease burden,
through various mechanisms. The insurers and health providers
are mandated to report the data of all cancer patients to the CAC
on an annual basis. The CAC is a source of information of the
SINCan responsible for integrating the information to form the
National Administrative Registry of Cancer (RANC)
SINCan
The available sources within the SINCan are administrative and
hospital records; as well as population studies and surveys. The data
reported and collected from the local, territorial and national level
are integrated into a data warehouse that allows interoperability of
the sources, which is called the Social Protection Comprehensive
Information System (SISPRO) (Fig. 1). The National Cancer
Observatory consolidates the information of the SISPRO, RANC
and Cancer Population Registries in order to build the indicators
to monitor the situation in the country, the analysis plans, and
the information outputs as necessary tools to adequately manage
knowledge about mortality, morbidity, access to services and
actions for cancer control in Colombia.
Case definition
People with histopathological diagnosis of some type of in situ or
invasive cancer; people with clinical diagnosis of cancer, supported
and justified in clinical, biochemical, imaging or laboratory tests
appropriate in those for whom, due to any clinical condition
negative to its performance or contraindication, it was not possible
to perform histopathological confirmation until the cutoff date, but
who are being managed as cancer patients. For specific cancers,
codes of the International Classification of Diseases, Tenth Revision
(ICD-10) were used as follows: stomach (C16); colorectal (C18 to
C21); breast (C50); Cervix (C53) and prostate (C61).
Collection instrument
Structured form that collects information in the following aspects:
General identification of the health insurer and the reported user
(Questions (Q) 1-16); General information related to diagnosis,
staging and treatment objectives (Q 17-41); antecedents that
precede the diagnosis of the cancer reported (Q 42-73);
specific surgery information (Q 74-85); radiotherapy specific
information (Q 86-105); specific information on hematopoietic
stem cell transplantation (Q 106-110); specific information on
complementary treatment (Q 111-124); current situation of the
user at the cut-off date (Q 125-132)
Information quality control in the High Cost Diseases Fund (CAC)
The CAC audits the information given by the EAPB against the
clinical records. Its objective is to verify the authenticity of the
data reported and to be able to accurately conclude the available
information. This process consists of two main components: the
first refers to the audit carried out by the information system;
through a validation mesh and the second, of the information
against the medical record.
 Ramirez-Barbosa P/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)
Integration to SISPRO
Platform (Data highway)

Population Population-based
Studies Cancer Registry

Mortality and Web Portal MSPS

vitals statistics SISPRO
DANE
SQL
Data Storage Access to cubes
Administrative of information
and Hospital SISPRO
National SISPRO
Records
Cancer
Observatory Digital
Public Health (ONC) Institutional
Surveillance Repository

Cancer Registry
SISPRO
High Cost
Geographic
Account
Module
(CAC)

Public
Advocate

Quality
control
1 4
2 3
Information Access and
Data Knowledge
Sources Diffusion
Management Management
Management Channels

Figura 1. National Cancer Information System of Colombia

Process of creating the CAC indicators
The development of the consensus done among the different actors
of the General System of Social Security in Health in Colombia
for the identification of indicators in cancer arose from the need
to evaluate and monitor risk management in cancer carried out by
insurance entities and health service providers, in order to be aligned
and contribute to the strategies that the country has implemented
for cancer control, such as the 10-year plan for cancer control in
Colombia1, clinical practice guidelines, and comprehensive care routes
for different types of cancer; this way generating control mechanisms
and providing a guide to health professionals, insurance entities,
providers and other actors in the search for a better risk management
in health that contributes to decrease clinical variability, reduce the
complications of the disease, improve survival and the quality of life
of patients, and control spending on health.
The consensus has been developed by the High Cost Diseases Fund
since 2016, giving priority to the most prevalent types of cancer in
Colombian society, and according to the priorities of the Ministry
of Health; To this end, the concepts of the methodological manual
of deliberation and participation of the Institute of Technological
Evaluation in Health (IETS in Spanish) were adopted, and the
methodology proposed by the methodological guide for the
preparation of clinical practice guidelines was adapted. These
guidelines present the technical processes for the formulation of
the research question, the review of the literature, the grading
of the scientific evidence and the process for the selection
and construction of the indicators7,8  . For the selection and
construction of the indicators, an adaptation of the methodology
“The RAND/UCLA Appropriateness Method (RAM)” was carried
out9, which allows combining the best available scientific evidence
with the collective judgment of the experts, in this case, thematic,
methodological and administrative. For the structuring of the
question, the PICO strategy was taken into account10,11  , which
was presented for each of the types of cancer worked on and
then an online application created for the virtual development
of the consensus was designed, where the research question, the
objectives, the scope, and the limitations were socialized and there
was a space for participation for the actors involved.
A search and critical reading of literature was carried out and it
was classified according to the type of scientific evidence, using
the AGREE II instrument12  for the qualification of the clinical
practice guidelines and the recommendations of the GRADE
system  13  for the qualification of the review articles. Once the
evidence was available, we extracted the recommendations and
definitions of interest, which were reviewed and adjusted by the
participants through the virtual forum, from there the possible
indicators were generated (the type of these: process or result), the
name, the description, the population object of application (total
of cases or new cases) and the different guidelines and articles that
supported the recommendation.
Finally, a group of indicators was defined and evaluated through
two virtual and a third face-to-face votes. The consensus
participants determined if the proposed indicators were
appropriate and met three essential criteria: relevance of the
indicator; feasibility, understood as the possibility of accessing the
sources of information from where the data will be obtained and
the validity of the content or measurement that reflects what is
intended to be measured, in this case, the indicator or indicators
that allow evaluating risk management in patients with cancer.
Risk management indicators for different types of cancer are
appended as a supplement.

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Table 1. High Cost Diseases Fund, Colombia. Number of new cancer cases for selected sites notified by health insurers during 2015.
Breast Prostate Cervix Colon Stomach Total
City
C50 C61 C53 C18-C21 C16
♂ ♀ ♂ ♀
Cali 235 273 59 69 80 51 42 809
Pasto 17 14 12 5 1 13 4 66
Bucaramanga 47 19 8 13 15 11 10 123
Manizales 58 29 15 13 27 20 8 170
Barranquilla 132 90 35 28 37 7 5 334
Medellín 498 250 134 103 134 80 71 1,270
Total 987 675 263 231 294 182 140 2,772
Source: Database High Cost Diseases Fund,

Analysis plan
With the information reported to the CAC with a cutoff date
of January 1, 2015, the baseline was calculated for each of the
indicators with available information. According to the result,
the cut points were defined according to the quintiles of each
indicator. For the indicators without baseline, the standards were
defined with the support of the clinical experts and the findings of
the literature review.
The final indicators for the measurement of risk management were
established with the agreement of all the participants in the third
virtual meeting and the consensus was finalized. Based on this, the
information is analyzed every year and weaknesses and strengths
of the cancer management process are identified.
For this occasion, the results of the risk management indicators for
five types of cancer (breast (only in women), cervix, prostate, colon
and rectum and gastric) in a population that is affiliated with the
General Social Security System in Health will be described in six
cities of the country (Barranquilla, Bucaramanga, Cali, Manizales,
Medellin and Pasto) where population registries operate, as a
complement to the analysis and approach of interventions for
cancer control.
in the registry. These were divided into four large groups of
indicators: diagnostic and staging (indicators 1 to 7), treatment
(indicators 8 to 12), opportunity (indicators 13 to 17) and results
(indicators 18 to 19). It can be seen that the city of Cali had
the highest proportion of patients with breast cancer who were
diagnosed in situ or early stages, while Barranquilla and Pasto had
the lowest proportions. Regarding the staging indicators, none of
the six municipalities obtained the defined standard to consider
the result as optimal, However, Medellin, for the new cases, is the
one with the highest proportion of staged cases registered. The
indicators related to the performance of diagnostic tests showed
a low proportion of women with breast cancer and who had
hormone test results, in terms of HER2 test results the proportion
increased in the six cities, with Bucaramanga achieving the value
considered as optimal.
In the field of treatments such as radiotherapy, anti-Her2 therapy
or administration of hormonal block, the results were located in
the ranges considered as bad or moderate (red and yellow scored
card) in most of the municipalities selected according to the
standard of measurement of the Consensus, Cali and Medellin
presented the highest proportion of patients with carcinoma  in
situ who underwent breast-conserving surgery.

The data comes from the administrative registry of cancer issued
by the Ministry of Health and Social Protection (Resolution 0247
of 2014) and corresponds to the new cases reported (diagnosed)
between January 2, 2015 and January 1, 2016.
We proceeded with the calculation of each of the indicators
included in the evidence-based consensus designed by the High
Cost Diseases Fund, which measures risk management by insurers
and providers for patients with each type of cancer previously
mentioned and that have defined standard cutoff points with a
color for each indicator, which reflects whether the result is good
(green), moderate (yellow) or bad (red).
Statistical software Stata 13 was used to process the data.
In the third group of indicators, related to opportunity times, none
of the cities analyzed presented a level considered optimal according
to the established standards, the times for diagnosis, medical care
and start of treatment presented prolonged times, above 60 days
for general care, that is, from the consultation for the presence of
symptoms associated with cancer up to the first treatment, however,
cities such as Medellin and Pasto are close to the appropriate range.
In terms of outcome indicators: mortality according to stage and
mortality, the city with the best results was Medellin.
Prostate cancer
A total of nine indicators were developed for prostate
cancer15  (Table 3), however 6 were susceptible to measurement,
due to the absence of information in the registry.

For prostate cancer, two opportunity times were measured: from

Results
Table 1  describes the number of new cancer cases prioritized
in the Ten-Year Plan for Cancer Control in Colombia that were
notified to the CAC during 2015 in the six cities studied.
Breast cancer
A total of 21 indicators were included in the consensus14 (Table 2),
however, 19 were measured due to the availability of information
131
the medical suspicion for the first consultation until the diagnosis
and from this until the start of the first treatment. For each one it
was established that a time less than 30 days was adequate to be
considered a good result. None of the cities obtained this result.
The largest proportion of patients staged with the TNM system
occurred in the cities of Manizales and Medellin, and those with
the highest number of patients studied in localized stages were
Bucaramanga and Medellin.
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Table 2. Risk management indicators in breast cancer by city of residence

1. Proportion of women 2. Proportion of women 3. Proportion of women 4. Proportion of women 5. Proportion of patients
with breast cancer who with breast cancer detected with breast cancer detected with breast cancer detected with histopathological
underwent TNM staging as carcinomas in situ at the in early stages at the time in advanced stages at the diagnosis before surgery
time of diagnosis of diagnosis time of diagnosis

< 71.5% < 6% < 42% > 58% < 38.6%

71.5 - 78.6% 6 - 11% 42 - 49% 50 - 57% 38.6 - 57.7%
City > 78.7% > 12% > 50% < 50% > 57.8%

Barranquilla 52.9% 10.0% 41.7% 58.3% 77.8%

Bucaramanga 66.3% 0.0% 44.1% 55.9% 52.6%
Cali 52.9% 16.9% 50.7% 49.3% 65.3%
Manizales 61.8% 4.9% 43.6% 56.4% 76.9%
Medellín 72.0% 8.0% 49.7% 50.3% 85.2%
Pasto 46.2% 9.1% 20.0% 80.0% 66.7%
Total 62.2% 8.8% 47.4% 52.6% 77.4%

6. Proportion of 8. Proportion of 8.1 Proportion of 9. Proportion of 10. Proportion of

women with breast women with breast women with invasive patients with breast women with positive
cancer resulting in 7. Proportion of cancer in situ who breast cancer who cancer who underwent hormone receptors who
hormone receptors patients with HER2 underwent breast-con- underwent breast-con- radiotherapy after are given hormonal
(estrogen / progestero- study serving surgery serving surgery breast-conserving blocking as treatment
ne) surgery
< 70% < 70% < 18.9% < 18.9% < 70% < 80%
70 - 89% 70 - 89% 18.9 - 65.3% 18.9 - 65.3% 70 - 89% 80 - 89%
City
> 90% > 90% > 65.4% > 65.4% > 90% > 90%

Barranquilla 56.8% 79.8% 33.3% 51.9% 27.3% 14.8%

Bucaramanga 70.2% 97.9% *** 40.0% 40.0% 21.1%
Cali 55.7% 76.5% 77.8% 61.5% 44.7% 18.1%
Manizales 50.0% 87.5% 100.0% 40.0% 0.0% 16.0%
Medellín 68.1% 87.9% 65.0% 63.9% 51.9% 13.4%
Pasto 47.1% 81.3% 0.0% 0.0% *** 28.6%
Total 62.3% 84.5% 64.7% 59.8% 45.7% 15.2%

12.1 Proportion of patients

11. Proportion of HER2 (+) with invasive breast cancer
13. Opportunity for 14. Opportunity for 15. Opportunity for care by
patients with anti-HER2 with assessment for general care cancer care the attending physician
therapy palliative care, advanced
stages (CNR)

< 34.1% > 75 days > 45 days > 30 days

34.1 - 69% to be decided 61 - 75 days 31 - 45 days 16 - 30 days
City > 70% < 60 days < 30 days < 15 days

Barranquilla 36.8% 2.4% 85.1 60.2 22.2

Bucaramanga 50.0% 5.3% 102.6 61.8 33.2
Cali 41.4% 5.9% 99.5 65.9 27.4
Manizales 25.0% 0.0% 82.8 45.8 19.5
Medellín 32.3% 9.2% 62.7 46.2 19.4
Pasto 0.0% 0.0% 61.3 50.8 33.8
Total 34.6% 6.6% 74.6 52.2 21.8

16. Opportunity to 17. Opportunity to start 18. Lethality of breast 18. Breast cancer lethality 19. General mortality
start treatment adjuvant therapy cancer (early stages) (late stages) in breast cancer

> 30 days > 56 days > 2% > 5% > 14.9 x 100000

16 - 30 days 43 - 56 days 1.3-2% 4.4-5% 9.9 -14.9 x 100000
City < 15 days < 42 days < 1.3 % < 4.4 % < 9.8 x 100000
Barranquilla 50.4 57.6 4.3% 6.4% 11.4
Bucaramanga 43.1 79.5 4.0% 5.0% 9.2
Cali 76.3 63.3 2.9% 8.2% 13.2
Manizales 34.4 64.2 2.7% 3.7% 7.5
Medellín 42.7 57.8 0.5% 3.8% 9.2
Pasto 31.2 44.0 9.5% 0.0% 6.5
Total 48.8 60.2 1.8% 5.1% 10.5

Source: High Cost Diseases Fund Database Resol 0247/14 - Cut-off date: January 01, 2016

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Table 3. Risk management indicators in prostate cancer by city of residence

1. Diagnostic opportunity in
3. Proportion of 4. Proportion of pa-
days; time between consulta- 6. Treatment opportu-
2. Proportion of pa- patients with locali- tients with locally ad- 5. Proportion of pa-
tions where remission is made nity in days, time
tients with prostate zed prostate cancer vanced and advanced tients staged in Glea-
due to clinical or paraclinical between diagnosis
cancer staged in TNM (patients in stage 0, I prostate cancer (stage son score
suspicion, associated with pros- until the first treat-
and II) III and IV patients)
tate cancer until diagnosis.

> 60 days < 50 % < 62% > 37% < 83% > 60 days
30 - 59 days 50 - 56% 62 - 69% 31 - 37% 83 - 87% 30 - 59 days
City
< 30 days > 56% > 69% < 31% > 87% < 30 days

Barranquilla 72 35.6% 56.3% 43.8% 79.3% 60

Bucaramanga 164 52.6% 70.0% 30.0% 85.7% 59
Cali 49 12.5% 61.8% 38.2% 60.0% 88
Manizales 112 62.1% 66.7% 33.3% 48.3% 61
Medellín 46 70.0% 74.3% 25.7% 93.1% 66
Pasto 43 7.1% 0.0% 100.0% 88.9% 64
Total 56 40.0% 69.6% 30.4% 78.4% 70

Source: High Cost Diseases Fund Database Resol 0247/14 - Cut-off date: January 01, 2016

The cities of Medellin and Pasto were the cities with the highest
proportion of patients in the Gleason score, while the city of
Manizales had the lowest proportion.
Cervical cancer
The total number of indicators measured for cervical cancer were
12 out of a total of 14 from the consensus14 (Table 4), which, like
the breast cancer indicators, were divided into four large groups:
diagnostic (indicator 1), treatment (indicators 2 to 6), opportunity
(indicators 7 to 10) and outcome (indicators 11 to 12).
Diagnostic measured the proportion of women who had clinical
staging in the new cases, it being higher in Manizales and Pasto. On
the other hand, Barranquilla and Cali had the lowest proportions.
In treatment, Bucaramanga was the city with the highest
proportion of women who underwent some healing procedure
in stages IA-IB1, with respect to the supply of radiotherapy in
stages II to IV, Pasto reported 100% of their patients receiving this
therapy, the cities of Barranquilla and Bucaramanga presented the
highest proportions in terms of the number of women living in
these cities receiving chemotherapy.
The cities of Pasto, Medellin and Barranquilla reported times
under 60 days between the time of clinical suspicion and the start
of treatment. Considering the different opportunity times in a
disaggregated way, Pasto presented the shortest times between the
different moments of attention.
Stomach cancer
A total of 12 indicators of the 16 considered in the consensus
were measured 16 (Table 5). In terms of opportunity times for the
diagnosis, Barranquilla and Medellin had the shortest times with
23 and 25 days, respectively. Regarding the time for the start of the
first treatment after confirmation of the diagnosis Medellin was
the city with the shortest time reported with 41 days, in contrast
to Barranquilla, which was the city where the entities reported the
highest times with 84 days.
Medellin was the city with the highest proportion of patients with
TNM staging and Barranquilla was the one with the highest proportion
of staged patients in early stages. These two cities were those that in
terms of treatment had the highest proportion of patients in stages 0
to III who were subjected to surgery as a curative treatment.

Table 4. Risk management indicators in cervical cancer by city of residence

2. Proportion of women 5. Proportion of women
with cervical cancer in 6.1 Proportion of
1. Proportion of women with stage IA-IB1 3. Proportion of women 4. Proportion of women
stages II-IV who were women with cervical
with cervical cancer who cervical cancer who with stage II-IV cervical with cervical cancer in
given chemotherapy and cancer with assessment
underwent clinical received some curative cancer who were given stages II-IV who were
concomitant radiothera- for palliative care,
staging, CNR procedure (conization / radiotherapy given chemotherapy.
py with brachytherapy advanced stages CNR
surgery).
<69% <60% <45% <49% <60%
69-78% 60-89% 45-62% 49-65% 60-89% to be decided
City
>78% >90% >62% >65% >90%

Barranquilla 58.6% 25.0% 84.6% 92.3% 0.0% 7.7%

Bucaramanga 71.4% 100.0% 66.7% 66.7% 0.0% 0.0%
Cali 54.7% 0.0% 39.1% 21.7% 0.0% 8.7%
Manizales 84.6% 0.0% 77.8% 33.3% 22.2% 0.0%
Medellín 76.9% 67.4% 83.0% 61.7% 0.0% 17.0%
Pasto 100.0% 0.0% 100.0% 9.1% 0.0% 0.0%
Total 71.1% 55.7% 74.5% 49.1% 1.9% 10.4%

11. Proportion of
women with cervical 12. General mortality
7. Opportunity for 8. Opportunity for 9. Opportunity for 10. Opportunity to
cancer with new in women with
general care cancer care treating doctor start treatment
diagnosis (within the cervical cancer
reporting period)
> 75 days > 45 days > 45 days > 30 days > 8.2 x 100000
61 - 75 days 31 - 45 days 31 - 45 days 16 - 30 days to be decided 5.5 - 8.2 x 100000
City
< 60 days < 30 days < 30 days < 15 days < 5.5 x 100000

Barranquilla 56.3 65.6 18.1 41.1 7.9 4.0

Bucaramanga 91.3 60.3 18.6 37.5 5.8 4.3
Cali
97.3 86.9 35.8 50.7 7.2 6.0
Manizales 68.9 55.9 18.8 46.3 10.0 8.1
Medellín 55.0 42.8 18.7 32.2 13.1 5.2
Pasto
36.7 28.8 21.4 14.0 9.4 8.8
Total
62.3 51.9 21.8 35.6 9.6 5.6

Source: High Cost Diseases Fund Database Resol 0247/14 - Cut-off date: 01 January 2016

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Table 5. Risk management Indicators in stomach cancer by city of residence

2. Proportion of 3. Proportion of new 4. Proportion of 6. Opportunity
1. Diagnostic 5. Treatment
patients with gastric cases identified in patients with TNM between neodyuvance
opportunity opportunity
cancer classified in situ early stages staging and curative surgery

> 60 days < 1.8% < 8% < 55% > 60 days > 12 weeks
30 - 59 days 1.8 - 3.4% 8 - 12% 55 - 60% 30 - 59 days < 12 weeks (84
City
< 30 days > 3.4% > 12% > 60% < 30 days days)
Barranquilla 22.7 0.0% 66.7% 50.0% 84 ***
Bucaramanga 91.3 0.0% 11.1% 42.9% 71 49.0
Cali 40.0 2.9% 27.3% 36.6% 49 93.5
Manizales 31.9 0.0% 28.6% 50.0% 46 ***
Medellín 25.2 1.9% 29.7% 68.2% 41 50.5
Pasto 33.0 0.0% 16.7% 35.3% 42 ***
Total 34.1 1.7% 29.0% 53.4% 47 67.4

8. Proportion of stage 0 13. Proportion of

7. Opportunity between 12.Proportion of
to III patients post-surgical patients 15. Overall 16. Operative
surgery and the start patients with nutrition
undergoing surgery as a with nutritional mortality rate mortality
of adjuvant assessment
curative treatment support

> 12 weeks < 20% <14% < 22% > 20%

< 12 weeks 20-27% 14 - 17% 22 - 33% to be decided
City < 20%
(84 days) >27% > 17% > 33%
Barranquilla 69.0 40.0% 16.7% 0.0% 1.4 0.0%
Bucaramanga 20.0 25.0% 19.0% 0.0% 7.9 25.0%
Cali 52.3 7.1% 29.0% 26.7% 7.1 0.0%
Manizales *** 0.0% 0.0% 100.0% 8.5 0.0%
Medellín 54.2 40.7% 19.2% 14.3% 6.2 0.0%
Pasto 63.0 0.0% 5.9% 0.0% 4.9 0.0%
Total 54.1 29.2% 19.6% 16.4% 5.9 1.5%
Source: High Cost Diseases Fund Database Resol 0247/14 - Cut-off date: January 01, 2016

Bucaramanga was the only city to report cases of people with the
disease who died within the first 30 days of the postoperative period.
Colon and rectum cancer
The total numbers of indicators included in the consensus were
1516 (Table 6), of which, due to the availability of the information,
12 were measured. In terms of opportunity times, Pasto and
Barranquilla had the shortest time to confirm the diagnosis, 11
and 27 days respectively; Bucaramanga presented the shortest
time to start treatment. Manizales and Medellin were the cities
with the highest proportion of patients with TNM staging.
In terms of treatment, given by patients who underwent surgery
with curative intent, the highest proportion of cases occurred
in the city of Pasto. However, none of the cities reached the
established standard.
Discussion
In different parts of the world, the development of indicators to
evaluate the quality of cancer care has gained great importance
due to the public health problem that it represents and how close to
30% of cases with this group of diseases could be avoided. Likewise,
cancer is currently affecting countries especially in low and middle
levels in the Human Development Index, where more than 60% of
cases occur17. It is urgent that governments know and monitor the
actions carried out by the different factors that have influence in
patients having access to quality health services and on time.
In Colombia, the measurement of indicators for the evaluation and
monitoring of risk management is of great importance in order to
determine whether the actions against cancer are being carried
out correctly in the country and otherwise, to take effective and
efficient measures to correct it.
The results for each type of cancer in the different cities are
heterogeneous and show strengths and weaknesses for each of
the cities and within the processes of caring for a cancer patient.
The results can be approximated and be a reflection of the reality
of the care process. However, there may also be weaknesses in
the reporting to the High Cost Diseases Fund, with incomplete
information on the part of the insurers, especially since the
registry has been operating for a few years only. Likewise, the
attention process is not only different according to illnesses but
they also manifest themselves in a different way in each person,
with certain particularities and therefore with specific times of
opportunity for each one of them. However, when observing the
defined standards in each of the consensus reached, a common
agreement is obtained stating that for these solid characteristic
neoplasms, the average time that should elapse from the moment
the first doctor who has the clinical and paraclinical tools makes
the decision to refer the patient for diagnostic confirmation until
the first treatment is performed, there should be about 60 days in
total for it to be considered good management.
It is also important to mention that the differences between cities
for certain types of cancer may be due to their geographical location

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Tabla 6. Risk management indicators in colon and rectal cancer by city of residence
7. Opportunity
9. Proportion of stage
between neoadjuvant 8. Opportunity 11. Proportion of
I to III patients under- 14. Overall 15. Incidence of colon
and curative surgery between surgery and patients with nutrition
going surgery as a mortality rate and rectum cancer
in patients with the start of adjuvant assessment
curative treatment
rectal cancer

> 12 weeks < 60% < 8%

> 8 weeks(56 days)
(84 days)
60 - 90% 8 - 11% to be decided to be decided
City 8-12 weeks < 8 weeks > 90% > 11%

Barranquilla *** 68.00 29.2% 9.2% 2.9 5.2

Bucaramanga 131.50 77.00 44.4% 7.1% 6.4 4.9
Cali *** 86.50 15.4% 10.7% 6.3 6.1
Manizales *** 49.00 29.4% 5.0% 9.3 10.1
Medellín 8.00 56.53 38.7% 13.1% 6.8 9.3
Pasto *** 76.00 50.0% 0.0% 2.2 1.3
Total 90.33 61.68 32.5% 10.9% 5.9 6.9
Source: High Cost Diseases Fund Database Resol 0247/14 - Cut-off date: January 01, 2016

in the country and the availability of specialized personnel for the
number of inhabitants and people with the disease in each one
of them. According to figures from the National Cancer Institute
in 2016  18  , the largest offer of oncological services in Colombia
are concentrated in: Bogotá (25.1%), Antioquia (12.7%), Valle del
Cauca (10.7%), Atlántico (9.1%) and, to a lesser extent, Santander
(6.6%). Similarly, each capital city of these departments offers more
than 88% of the cancer services available in their department 18.
The indicators with the best results were those related to detection
in early stages, especially in gastric and colorectal cancer, these
are cancers that require a specialized process for their diagnosis,
different from those of the breast and cervix. However, the
indicator that measures the proportion of patients with staging
was low for most types of cancer, this is possibly due to the lack
of reporting by insurers for this item, since staging is essential to
know the extent of the disease and to plan a treatment.
With respect to treatment indicators, these usually vary by cities
and by type of cancer without evidencing a clear pattern which
can be explained more than by variations in the definition
or standardization of treatments by regions of Colombia to
differences and deficiencies in reporting, with many cases of lack
of knowledge on the part of some insurers about how to report a
medication or a particular treatment. Although the country has
Clinical Practice Guidelines, comprehensive care routes and other
protocols applicable to the entire country.
In the treatment of gastric and colon and rectum cancer, some of the
most relevant indicators are those related to nutrition assessment,
given that the nutritional status of patients with cancer can vary both
in the initial symptoms and during the progression of the disease.
It has been described in the literature that between 30 and 85% of
cancer patients suffer from malnutrition, with this being a risk factor
for other outcomes19. However, the results show that work must
be continued to reach the proposed goal, especially in the cities of
Manizales and Pasto, which had the lowest patient proportions.
In terms of opportunity times, gastric cancer was the one that
showed the best results, with shorter times, especially between
neoadjuvant and curative surgical management and between it
and the onset of adjuvant therapy.
The measured indicators show an overview of the situation in
the management of cancer by insurers in these cities, and this is
considered the first step and an important input that contributes
to generating information for making assertive decisions for
the improvement of the quality of care for people with cancer
in these cities. This articulation with the population registers
for the realization of studies is crucial where causality analysis
is carried out and each type of cancer is analyzed in detail. This
offers the possibility of extending it to other regions in order to
identify inequalities in the care process by regions but, above all,
to intervene with the aim of achieving equity.
Conflict of interest:
Authors report no conflicts of interest
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CONSENSO_camamacerv_PDF_V_0_A5-WEB.pdf.
15. Cuenta de Alto Costo. Consenso basado en evidencia:
indicadores de gestión del riesgo en pacientes con cáncer de próstata
en Colombia. Bogota: Fondo Colombiano de Enfermedades de
Alto Costo; 2017. Available from: https://cuentadealtocosto.org/
site/images/Publicaciones/consenso cancer de prostata.pdf.
16. Cuenta de Alto Costo. Consenso basado en evidencia:
indicadores de gestión del riesgo en pacientes con cáncer
gástrico y cáncer de colon y recto en Colombia. Bogotá:
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CANCERCOLONRECTO_PDF_V_0_A11.pdf.
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18. Jairo Aguilera-López, Murcia-Monroy EM. Servicios
Oncológicos en Colombia. Bogota: Instituto Nacional de
Cancerologia; 2016. Available from: http://www.cancer.gov.co/
files/libros/archivos/ Servicios Oncologicos Boletín.pdf.
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Caccialanza R, et al. The nutritional risk in oncology: A study of 1,
453 cancer outpatients. Support Care Cancer. 2012;20(8):1919-28.
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Colomb Med. (Cali) 49(1): 128-136
 Pardo C/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Supplementary material. 
Table S1. Cancer incidence and mortality, 25 cancer categories. Colombia, 2007-2011
Incidence Cases (year) Rates (Men) Rates (Women) Observed deaths (year) Rates (men) Rates (women)
Cancer category
Total Men Women CR ASR CR ASR Total Men Women CR ASR CR ASR
All cáncer witout skin 62,818 29,734 33,084 133.9 151.5 145.3 145.6 32,653 16,081 16,572 72.4 82.3 72.8 73.2
Lips, Oral cavity and pharynx 1,494 787 707 3.5 4.0 3.1 3.1 501 295 206 1.3 1.5 0.9 0.9
Esophagus 864 573 291 2.6 3.0 1.3 1.3 664 451 213 2.0 2.3 0.9 0.9
Stomach 5,955 3,613 2,342 16.3 18.5 10.3 10.3 4,537 2,767 1,770 12.5 14.2 7.8 7.8
Colorrectal 2,401 2,784 10.8 12.2 12.2 12.3 2,544 1,168 1,376 5.3 6.0 6.0 6.1
Liver 1,138 541 597 2.4 2.8 2.6 2.6 1,621 762 859 3.4 3.9 3.8 3.8
Gallblader 1,098 281 817 1.3 1.4 3.6 3.6 776 228 548 1.0 1.2 2.4 2.4
Pancreas 1,191 512 679 2.3 2.6 3.0 3.0 1,269 583 686 2.6 3.0 3.0 3.0
Larynx 693 575 118 2.6 3.0 0.5 0.5 377 302 75 1.4 1.6 0.3 0.3
Trachea,, bronchi, lung 3,985 2,488 1,497 11.2 12.9 6.6 6.6 3,890 2,357 1,533 10.6 12.2 6.7 6.8
Skin melanoma 1,203 590 613 2.7 3.0 2.7 2.7 226 121 105 0.5 0.6 0.5 0.5
Breast 7,627 … 7,627 … … 33.5 33.8 2,226 … 2,226 … … 9.8 9.9
Cervix 4,462 … 4,462 … … 19.6 19.3 1,861 … 1,861 … … 8.2 8.2
Utero body 771 … 771 … … 3.4 3.5 187 … 187 … … 0.8 0.8
Ovary and others 1,279 … 1,279 … … 5.6 5.6 712 … 712 … … 3.1 3.2
Prostate 8,872 8,872 … 40.0 46.5 … … 2,416 2,416 … 10.9 12.6 … …
Testícle 507 507 … 2.3 2.2 … … 72 72 … 0.3 0.3 … …
Kidney 961 537 424 2.4 2.7 1.9 1.9 379 213 166 1.0 1.1 0.7 0.7
Bladder 1,144 863 281 3.9 4.5 1.2 1.3 401 266 135 1.2 1.4 0.6 0.6
Encephalon, SCN others 1,273 702 571 3.2 3.4 2.5 2.5 952 516 436 2.3 2.5 1.9 1.9
Thyroid 2,448 247 2,201 1.1 1.3 9.7 9.4 219 56 163 0.3 0.3 0.7 0.7
Lymphoma Hodgkin 339 229 110 1.0 1.0 0.5 0.5 119 74 45 0.3 0.4 0.2 0.2
Lymphoma no Hodgkin 2,744 1,542 1,202 6.9 7.5 5.3 5.3 939 518 421 2.3 2.6 1.8 1.9
Leukemia 2,473 1,256 1,217 5.7 6.0 5.3 5.4 1,610 869 741 3.9 4.2 3.3 3.3
Other places/not especified 5,112 2,618 2,494 11.8 13.1 11.0 11.0 4,155 2,047 2,108 9.2 10.4 9.3 9.3
CR:Crude rate
AAR:age-adjusted rate (per 100,000 year-person).

Cancer Incidence and mortality, Departments, Colombia, 2007-2011.

Departamet Total Men Women CR ASR CR ASR Total Men Women CR ASR CR ASR
Colombia 62,818 29,734 33,084 133.9 151.5 145.3 145.6 32,653 16,081 16572 72.4 82.3 72.8 73.2
Antioquia 9,781 4,606 5,175 157.4 173.1 169.0 159.9 5,419 2638 2781 90.2 99.7 90.8 86.2
Arauca 253 121 132 98.0 144.3 109.1 148.4 113 55 58 44.5 67.0 47.9 68.9
Atlántico 3,010 1,371 1,639 121.7 147.9 141.5 144.9 1,447 695 752 61.7 75.3 64.9 67.5
Bogotá 11,068 4,924 6,144 140.8 167.7 163.3 158.0 5,608 2607 3001 74.6 90.1 79.7 78.5
Bolívar 2,019 983 1,036 100.4 120.8 105.8 113.7 961 496 465 50.7 61.1 47.5 52.0
Boyacá 1,813 904 909 143.0 136.0 143.6 128.6 948 493 455 78.0 73.2 71.9 61.1
Caldas 1,860 871 989 182.2 171.2 198.5 170.4 1,008 499 509 104.4 97.5 102.2 85.5
Caquetá 447 229 218 102.6 132.0 99.6 127.4 226 117 109 52.4 68.6 49.8 66.4
Casanare 309 160 149 98.3 145.8 95.0 123.5 151 77 74 47.3 71.8 47.2 65.2
Cauca 1,521 726 795 109.5 122.2 123.2 128.6 788 394 394 59.5 66.0 61.0 63.2
Cesar 990 497 493 104.3 141.7 103.2 127.3 492 254 238 53.3 72.9 49.8 65.4
Chocó 279 145 134 61.8 99.7 56.5 78.2 128 66 62 28.1 45.0 26.2 37.1
Córdoba 1,356 687 669 87.8 105.5 86.2 97.6 661 330 331 42.2 50.6 42.6 49.0
Cundinamarca 3,157 1,546 1,611 127.0 135.0 132.0 129.9 1,649 851 798 69.9 74.2 65.4 63.7
Huila 1,451 740 711 137.9 160.3 133.6 145.9 773 410 363 76.4 88.9 68.2 74.6
La Guajira 440 214 226 54.7 83.0 56.6 72.6 201 100 101 25.5 38.8 25.3 33.5
Magdalena 1,249 634 615 105.5 133.0 104.2 122.2 633 329 304 54.8 69.5 51.5 61.6
Meta 1,206 594 612 138.5 166.9 144.3 167.9 616 313 303 73.0 88.7 71.4 86.2
Nariño 1,810 813 997 100.1 111.7 123.5 127.7 947 463 484 57.0 63.6 59.9 61.9
Norte de Santander 1,815 900 915 141.0 165.3 141.1 148.6 986 497 489 77.9 91.8 75.4 79.7
Putumayo 202 105 97 63.9 94.4 61.2 85.4 102 55 47 33.5 49.6 29.7 43.3
Quindío 1,172 557 615 207.7 195.5 220.9 193.3 616 318 298 118.6 111.2 107.1 91.5
Risaralda 1,723 828 895 184.7 182.4 189.9 168.6 958 469 489 104.6 103.2 103.8 91.0
San Andrés y Providencia 78 44 34 121.6 163.8 93.0 94.8 25 15 10 41.5 61.7 27.4 29.0
Santander 2,961 1,392 1,569 140.9 150.0 155.0 145.5 1,544 768 776 77.8 82.8 76.7 70.8
Sucre 737 360 377 88.5 100.4 95.2 103.6 379 186 193 45.7 52.0 48.7 53.4
Tolima 2,308 1,119 1,189 160.8 150.2 172.9 161.3 1,180 610 570 87.7 81.1 82.9 75.1
Valle del Cauca 7,639 3,582 4,057 170.1 179.6 181.7 167.1 4,015 1931 2084 91.7 96.8 93.3 85.1
Amazonas group * 164 82 82 50.6 82.1 54.0 83.4 79 45 34 27.8 47.4 22.4 37.3
TC: crude rate;
AAR: Age-adjusted rate (por 100,000)
*Amazonas, Guainía, Guaviare, Vichada y Vaupés

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Colomb Med. (Cali) 49(1): 16-22

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 Brome BMR/et al/Colombia Médica - Vol. 49 Nº1 2018 (Jan-Mar)

Supplementary material. 
Table S1. Municipality of Medellin, Colombia. Incidence data of malignant tumors prioritized in the Decade Cancer Control Plan in
Colombia during 2010-2014.
Age
Localization n 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Crude ASR
Desc
Breast (C50) 3,286 14 0.0 0.0 0.0 0.0 1.2 5.8 16.2 27.7 56.9 91.5 85.5 112.9 123.3 147.5 160.9 141.3 166.6 51.9 36.5
Cervix (C53) 708 1 0.0 0.0 0.0 0.2 1.4 9.0 12.9 20.0 18.0 17.2 17.4 21.2 16.6 20.7 15.0 9.2 19.1 11.2 8.5
Prostate (C61) 2,571 15 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.9 3.9 12.2 28.6 89.3 187.4 293.1 401.9 411.7 407.7 45.7 38.6
Colorrectal (C18-C20) 1,640 5 0.0 0.0 0.1 0.5 0.6 2.7 2.8 3.8 7.2 10.9 14.7 23.7 37.5 53.9 62.3 87.5 128.8 13.7 10.0
Men 747 3 0.0 0.0 0.0 0.6 0.6 3.1 3.5 2.0 5.2 11.6 14.3 24.1 40.7 66.1 72.4 99.0 149.7 13.3 11.0
Women 893 2 0.0 0.0 0.3 0.4 0.6 2.2 2.2 5.4 8.9 10.3 15.0 23.4 35.1 44.9 55.2 80.2 117.0 14.1 9.4
Colon (C18) 1,080 3 0.0 0.0 0.1 0.3 0.5 2.1 1.6 3.4 4.9 7.1 9.8 14.0 25.4 34.5 40.0 59.4 84.8 9.0 6.6
Men 474 3 0.0 0.0 0.0 0.4 0.6 2.5 1.7 1.7 3.6 7.7 10.4 13.3 27.0 39.5 47.4 60.4 90.6 8.5 7.0
Women 606 0 0.0 0.0 0.3 0.2 0.4 1.8 1.5 4.9 5.9 6.6 9.3 14.6 24.1 30.8 34.8 58.8 81.5 9.6 6.4
Rectum (C19-C20) 560 2 0.0 0.0 0.0 0.2 0.1 0.5 1.2 0.4 2.4 3.8 4.9 9.7 12.2 19.4 22.3 28.1 44.0 4.7 3.4
Men 273 0 0.0 0.0 0.0 0.2 0.0 0.6 1.7 0.3 1.6 3.9 4.0 10.8 13.7 26.5 25.0 38.6 59.1 4.8 4.0
Women 287 2 0.0 0.0 0.0 0.2 0.2 0.4 0.7 0.5 3.0 3.7 5.7 8.8 11.0 14.1 20.4 21.4 35.5 4.6 3.0
Stomach (C16) 1,209 12 0.0 0.0 0.0 0.0 0.4 1.6 3.6 3.8 4.6 7.7 10.4 17.4 25.2 35.8 60.9 66.0 88.0 10.2 10.1
Men 695 6 0.0 0.0 0.0 0.0 0.2 1.9 3.5 4.0 3.6 10.4 14.8 27.2 32.2 47.2 90.5 103.8 123.3 12.4 12.3
Women 514 6 0.0 0.0 0.0 0.0 0.6 1.4 3.7 3.6 5.4 5.4 6.9 9.8 19.7 27.3 40.2 42.0 68.1 8.2 8.1
All localizations 22,379 111 12.0 11.4 11.1 19.1 25.7 48.2 77.2 97.2 125.6 178.8 221.5 345.8 483.8 661.9 874.5 943.1 11,75.0 187.1 143.4
Men 9,602 43 13.9 11.7 11.1 18.0 22.7 33.7 48.6 52.6 71.4 116.8 160.7 309.5 524.3 793.8 1,125.0 1,295.0 15,74.0 171.3 144.4
Women 12,777 68 10.1 11.0 11.0 20.2 28.7 62.1 102.5 134.8 170.8 230.0 270.0 374.5 452.2 563.5 699.9 720.2 950.1 202.9 145.6
Non-invasive cervical
2,254 44 0.0 0.0 0.0 4.4 35.3 85.6 99.7 71.1 61.7 37.7 26.2 22.7 25.0 20.3 18.6 6.9 5.0 35.6 30.6
neoplasias
Infantile Leukemia 77 0 3.7 3.2 3.2 0.6 1.1
Men 38 0 3.7 3.4 2.7 0.7 1.0
Women 39 0 3.6 3.0 3.8 0.6 1.1
Source: Population-based Cancer Registry of Antioquia.

Table S2. Municipality of Medellin, Colombia. Mortality information of malignant tumors prioritized in the Decade Cancer Control
Plan in Colombia during 2010-2014.
10-
Localization n 0-4 5-9 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Crude ASR
14
Breast (C50) 1,075 0.0 0.0 0.0 0.2 0.0 1.2 2.6 7.5 11.3 19.1 24.5 27.1 41.6 51.1 73.2 62.6 129.7 17.0 12.9
Cervix (C53) 391 0.0 0.0 0.0 0.0 0.4 2.6 4.2 5.1 7.4 6.7 9.9 8.5 13.8 15.0 20.4 18.3 31.9 6.2 4.9
Prostate (C61) 798 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.5 0.2 1.7 7.1 25.4 46.6 99.2 142.4 489.5 14.2 14.6
Colorrectal (C18-C20) 1,216 0.0 0.0 0.1 0.3 0.4 0.9 1.9 1.8 3.7 6.3 8.3 14.0 21.7 37.6 62.3 63.6 142.4 10.2 7.2
Men 575 0.0 0.0 0.2 0.4 0.2 1.5 2.5 1.2 2.9 6.8 9.4 13.6 19.7 53.1 74.2 77.3 173.6 10.2 8.4
Women 641 0.0 0.0 0.0 0.2 0.6 0.4 1.3 2.4 4.3 5.8 7.5 14.4 23.2 26.0 54.0 55.0 124.8 10.1 6.5
Colon (C18) 1015 0.0 0.0 0.1 0.2 0.4 0.7 1.4 1.2 3.1 4.6 6.6 11.6 17.8 31.8 52.4 54.7 123.3 8.5 6.0
Men 476 0.0 0.0 0.2 0.2 0.2 1.0 2.2 0.6 2.6 5.4 7.2 11.4 16.9 44.8 58.6 64.0 148.5 8.5 6.9
Women 539 0.0 0.0 0.0 0.2 0.6 0.4 0.7 1.7 3.5 3.9 6.1 11.7 18.5 22.0 48.0 48.9 109.2 8.5 5.4
Rectum (C19-C20) 201 0.0 0.0 0.0 0.1 0.0 0.2 0.5 0.7 0.6 1.6 1.8 2.5 3.9 5.8 9.9 8.9 19.0 1.7 1.2
Men 99 0.0 0.0 0.0 0.2 0.0 0.4 0.2 0.6 0.3 1.4 2.2 2.2 2.8 8.3 15.5 13.3 25.2 1.8 1.5
Women 102 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.7 0.9 1.9 1.4 2.7 4.7 4.0 6.0 6.1 15.6 1.6 1.1
Stomach (C16) 1,467 0.0 0.0 0.0 0.0 0.3 1.3 2.9 4.2 4.7 8.2 13.2 16.1 27.5 39.8 71.1 87.9 151.0 12.3 10.3
Men 801 0.0 0.0 0.0 0.0 0.0 1.7 2.2 4.9 4.9 9.8 16.8 22.9 37.5 54.3 99.2 130.4 195.0 14.2 13.6
Women 666 0.0 0.0 0.0 0.0 0.6 1.0 3.5 3.6 4.6 6.9 10.3 10.7 19.7 29.1 51.6 61.1 126.2 10.5 8.0
All localizations 14,922* 5.3 5.3 5.2 10.0 8.1 10.0 20.9 27.3 37.9 65.6 106.3 172.2 282.4 450.0 703.6 897.7 1657.9 124.7 89.7
Men 6,941 4.5 5.5 3.6 12.2 9.0 10.0 17.3 20.5 27.5 58.5 98.3 178.4 318.4 520.7 845.1 1101.0 2129.0 123.3 101.1
Women 7,980 6.2 5.2 6.8 7.8 7.2 10.0 24.1 33.1 46.5 71.4 112.7 167.3 254.4 397.1 605.0 769.1 1391.8 126.0 82.6
Infantile Leukemia 46 1.2 2.3 2.5 0.4 0.6
Men 21 0.5 2.4 2.4 0.4 0.5
Women 25 2.0 2.2 2.5 0.4 0.7
*There is one case of mortality of unknown gender. Source: Population-based Cancer Registry of Antioquia.

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