Scientific Substantiation of the System of Prevention of Natural and Anthropogenic Risk Factors of Oncological Pathology in the Specific Conditions of the Primorsky Region

The dissertation is devoted to the scientific substantiation of the system of prevention of natural and anthropogenic risk factors of oncological pathology in the specific conditions of the Primorsky region. The study encompasses a comprehensive medical-social and ecological-hygienic investigation of the influence of the environment on the formation of malignant neoplasms among the population of Primorsky Krai. The work examines the medical-geographical, natural-climatic, ecological, and hygienic characteristics of the administrative territories of the Krai, as well as their influence on the prevalence of oncological diseases.

Within the framework of the research, a model of factor dependence for the formation of malignant neoplasms on various administrative territories has been developed, an integral index of the state of the habitat has been calculated, and risk territories according to malignant neoplasms have been determined. The structure, level, and dynamics of morbidity with malignant neoplasms, population mortality from oncological diseases, and the medical-social and economic characteristics of an oncology patient as a consumer of medical services have been studied. Organizational forms of systemic prevention of malignant neoplasms, taking into account the regional features of ecological load, have been proposed.

Relevance of the problem. The healthcare reform strategy provides for strengthening the role of the subjects of the Russian Federation in addressing social problems (Vyalkov A.I., 2000; Starodubov V.I., 2000; Mikhailova Yu.V., 2000; Polyakov I.V., 2001, et al.). The responsibility of the regions for the health status of the population, the level and quality of medical care has significantly increased (Shchepin O.P., 1998; Denisov I.P., 2000; Shevchenko Yu.L., 2001; Tishchuk E.A., 2001; Reshetnikov A.V., 2002, et al.).

For many regions, one of the most important problems is the need to eliminate the influence of risk factors for oncological morbidity and to reduce the level of morbidity, mortality, and disability (Dvoirin V.V., 1996; Merabishvili V.M., 2002; Parkin D.M., 1984; Muir C.S., 1986; Perera F.P., 1996).

In Russia, more than 400 thousand new cases of malignant neoplasms are registered annually (in the world - 10 million patients), and approximately 2 million patients are on the registry of the oncology service in the country, which constitutes 1.4% of the total population with an annual increase of 0.2%.

Economic losses from malignant neoplasms are significant (Trapesnikov N.N., Aksel E.M., 2001; Chissov V.I., Starinsky V.V., 2002, et al.). In the structure of causes of death, malignant neoplasms account for 13.3%, and in the structure of disability - up to 10.0%.

At the current stage in Russia, the development and improvement of preventive activity as the primary direction for reducing the most common and dangerous forms of disease is especially relevant (Ovcharov V.K., 1993; Oganov R.G., 1994; Potapov A.I., 1998; Lindenbraten A.L., 2000; Denisov I.N., 2001; Maimulov V.G., 2001; Onishchenko G.G., 2001; Vasilyeva T.P., 2002; Shevchenko Yu.L., 2002; Shchepin O.P., 2002; Yuryev V.K., 2002). It is necessary to improve the organizational forms of prevention, timely detection, and staged effective treatment of malignant diseases.

This is especially relevant and important for implementation in Primorsky Krai, which has an elevated level of impact on the population from natural and anthropogenic environmental factors.

The Ministry of Health of Russia has planned a federal program on oncology for implementation, which provides for reducing the primary incidence of disability, lowering the mortality rate, reducing economic damage, and improving oncology care for the population.

However, to date, there are insufficient scientific studies with a substantiation of preventive activity and improvement of organizational forms for timely detection and early diagnosis of oncological diseases. The priority of the impact of anthropoecological risk factors on the formation of oncological pathology has not been determined. Cancer registries are being created slowly, and questions of inter-territorial settlements for treated oncology patients are not being resolved in a timely manner. There are practically no developments on determining the population's need for hospital beds, special and pharmaceutical preparations for oncology patients. The existing inter-departmental program on oncology in medical universities is insufficient in volume and does not allow for the presentation of current information on the organizational forms of preventive and therapeutic-diagnostic activities of oncology medical institutions.

Goal of the study - scientific substantiation of the system of prevention of the impact of natural and anthropogenic risk factors on the formation of oncological pathology in the specific conditions of the Primorsky region.

Research objectives:

- to identify regional medical-geographical and ecological-hygienic features of the Primorsky Krai ecosystem with the determination of risk territories according to malignant neoplasms;

- to study the population-level, structure, dynamics, and topography of the distribution of malignant neoplasms among various population groups in the territory of Primorsky Krai;

- to identify factors influencing the formation and prevalence of oncological diseases. Calculate an integral index characterizing the state of the habitat according to specific modules (medical-geographical, medical-social, ecological, and hygienic) and present prognostic indicators of epidemiological risk for oncological pathology;

- to develop and implement a model of factor dependence for the formation of malignant neoplasms on various administrative territories of medical-geographical and ecological risk;

- to present the medical-social and economic characterization of an oncology patient as a consumer of medical services;

- to substantiate the criteria and system of accounting for the formation of disease monitoring and a cancer registry of patients, as well as population groups at risk of developing diseases, taking into account the actual carcinogenic load;

- to present a scientific substantiation and develop a regional system of prevention of oncological diseases, taking into account the impact of natural and anthropogenic risk factors.

Scientific novelty and theoretical significance of the study. For the first time, a program for a comprehensive medical-social and ecological-hygienic analysis of the formation of oncological diseases, taking into account the influence of natural and anthropogenic factors in the specific conditions of the Far Eastern region, has been scientifically substantiated and developed. The regional medical-geographical and ecological-hygienic features of the Primorsky Krai ecosystem have been studied, which have made it possible to determine risk territories according to malignant neoplasms. A medical-social study has made it possible to identify the main trends in studying the level and dynamics of territorial prevalence of malignant neoplasms among various population groups, and to determine priority directions for targeted organizational and preventive measures. For the first time, an integral index characterizing the state of the habitat according to specific modules of medical-geographical, medical-social, ecological, and hygienic characteristics has been calculated. It has been proven that the increase in oncological morbidity can be regarded as one of the markers of ecological and socio-hygienic distress on an administrative territory. For the first time, prognostic indicators of epidemiological risk for oncological pathology have been presented. For the first time, a model of factor dependence for the formation of malignant neoplasms on various administrative territories of medical-geographical and ecological risk has been developed and implemented. For the first time, the need for the volume and staged provision of the population with preventive measures and various types of medical care for oncology patients has been determined. For the first time, a medical-social and economic characterization of an oncology patient as a consumer of medical services has been presented. For the first time, measures for improving the system of accounting for the formation of disease monitoring and a cancer registry of patients have been developed and implemented. For the first time, a scientific substantiation of the organizational model and priority systemic medical preventive measures for early detection of oncological diseases, and for reducing disability and mortality, has been given.

Practical significance and implementation in practice. The study was carried out in accordance with the comprehensive program of the Research Institute of Medical Climatology and Rehabilitation of the Far Eastern Scientific Center of Physiology and Pathology of Respiration, Siberian Branch of the Russian Academy of Medical Sciences. The results of the study served as the scientific and informational basis for the creation of an organizational-functional model and diagnostic algorithms at the regional oncology dispensary for the early active detection of patients with precancerous and malignant pathology. The integral assessment of the complex of natural-climatic and ecological-hygienic factors made it possible to classify the ecosystem of Primorsky Krai according to the degree of ecological stress, and to identify the most significant habitat factors determining the class of the ecosystem. The use of a methodology for identifying population groups and territories of medical-social, ecological, and hygienic risk allows outpatient-polyclinic institutions and oncology dispensaries to conduct marketing research, determine the need for therapeutic and health-improving services, carry out economically viable planning, and forecast the dynamics of oncological morbidity. The developed and implemented program for the prevention of oncological diseases in Primorsky Krai, approved by the Governor (Resolution No. 200-19.03.01), has made it possible to coordinate the activities of therapeutic and preventive institutions, State Sanitary-Epidemiological Surveillance centers, and other departments interested in the systemic conduct of medical-social health-improving measures. Of important practical significance are the proposed measures for optimizing the system of accounting for the formation of disease monitoring and a cancer registry of patients. The medical and economic feasibility of providing medical care to patients in conditions of continuity between polyclinics, dispensaries, and multidisciplinary hospital inpatients has been substantiated. The use of a model of factor dependence for the formation of malignant neoplasms on various territories of medical-geographical and ecological risk is practically advisable, which has made it possible to improve the activities of inter-district oncology dispensaries and examination rooms of polyclinics for preclinical diagnosis of tumor diseases, and for organizing the work of palliative care rooms. The obtained data were used in the preparation of Resolution of the Government of the Russian Federation No. 163 (2000), in methodological recommendations approved by the Ministry of Health of the Russian Federation (2001), and in methodological recommendations approved by the Department of State Sanitary-Epidemiological Surveillance of the Russian Federation (2002). The materials of the study were implemented in the preparation of directive documents on the problems of oncological morbidity, primary disability, and mortality (2000-2002), approved by the Governor of Primorsky Krai. The developed passport, the regional target program "Oncology" (2002-2006), approved by the Administration of Primorsky Krai, and the created models for forecasting levels of oncological morbidity are used in the activities of the organizational and methodological department of the regional oncology dispensary and other healthcare institutions of Primorsky Krai. Developed and published methodological recommendations (6) for physicians of healthcare institutions of the Krai on questions of organizing the activities of inter-district oncology and polyclinic examination rooms, organizing preventive examinations for early and preclinical diagnosis of tumor diseases, organizing the detection of visual forms of cancer, and organizing the work of palliative care rooms. The results of scientific research have been implemented in the educational process and postgraduate training of specialists at the Vladivostok State Medical University and the Vladivostok branch of the Far Eastern Scientific Center of Physiology and Pathology of Respiration, Research Institute of Medical Climatology and Rehabilitation of the Siberian Branch of the Russian Academy of Medical Sciences.

Publications. On the topic of the dissertation research, 52 scientific works have been published, including: 3 monographs, 1 statistical collection, 9 methodological recommendations (3 at the federal level and 6 at the regional level), 14 in the central press, and other journal articles and materials of All-Russian and regional conferences.

Defense of the work. The main provisions of the dissertation were reported and discussed at the All-Russian Conference with international participation "The Impact of Environmental Pollution on Human Health" (Novosibirsk, 2002); the All-Russian Scientific Conference "Organizational Issues of Early Diagnosis, Prevention of Malignant Neoplasms, and Palliative Care for Oncology Patients" (Kazan, 2001); the 4th Russian Forum "Mother and Child" (Moscow, 2002); the 6th Russian Oncology Conference (Moscow, 2002); the All-Russian Scientific and Practical Conference "Assessment of Health Risk from Adverse Environmental Factors: Experience, Problems, and Solutions" (Angarsk, 2002); the 3rd Far Eastern International Symposium "Current Problems in Oncology" (Vladivostok, 1998); the 2nd Far Eastern Regional Conference with All-Russian Participation "New Medical Technologies in the Far East" (Vladivostok, 1998); the 2nd and 3rd Far Eastern Oncology Conferences "Questions of Diagnosis and Treatment of Malignant Tumors" (Vladivostok, 2000, 2001); the Regional Scientific and Practical Conference "Current Problems in Oncology" (Birobidzhan, 2001); the Regional Scientific and Practical Conference with All-Russian Participation "New Medical Technologies in the Far Eastern Region" (Khabarovsk, 2002); the Scientific and Practical Conference "New Technologies in Rehabilitation of the Most Common Non-Infectious Diseases" (Vladivostok, 2002); the Scientific and Practical Conference "Questions of Health and Pathology Formation in the North: Facts, Problems, and Prospects" (Yakutsk, 2002); the 4th Far Eastern Scientific and Practical Conference "Current Questions of Diagnosis and Treatment in Oncology" (Vladivostok, 2002); the Academic Council of the Institute of Medical Climatology and Rehabilitation of the Siberian Branch of the Russian Academy of Medical Sciences (Vladivostok, 2001, 2002), et al.

Author's personal contribution. The author developed the program for a comprehensive medical-social and ecological-hygienic study of the influence of natural and anthropogenic risk factors on the formation of oncological pathology among the population of Primorsky Krai. The collection of primary information was carried out by extracting data from statistical accounting forms of oncology institutions of Primorsky Krai and the regional oncology dispensary, from medical documentation and laboratories of the regional State Sanitary-Epidemiological Surveillance Center of Primorsky Krai, from the laboratories of recreational resources of the Institute of Medical Climatology and Rehabilitation of the Siberian Branch of the Russian Academy of Medical Sciences, the Eco-center of PO "Primorgeo," et al. The indicators of the ecological, hygienic, medical-geographical, and geochemical situation of 12 urban industrial centers and 25 districts of the territory of Primorsky Krai were analyzed. The prevalence of oncological pathology in the territory of the Krai for 1991-2001 was assessed. Indicators of morbidity, morbidity burden, and mortality from oncological diseases were calculated. Statistical processing with assessment of indicators was carried out personally by the author. With the participation of the author, an analysis of the influence of environmental indicators in urban conditions and rural settlements on the level of oncological pathology was conducted. A point assessment of ecological-hygienic characteristics was carried out for the determination of risk territories. The activity of medical institutions in the use of specialists and hospital capacity for oncology patients was analyzed. With the participation of the author, a computer program for mathematical analysis (cluster, factor, regression, standardization, correlation, et al.) was developed to establish causal relationships and forecast morbidity and mortality. A model of factor dependence for the formation of malignant neoplasms on territories of ecological risk was substantiated and developed. The population's need for therapeutic and preventive measures and medical care for oncology patients was determined. The author conducted a medical-sociological survey for the composition of the medical-social and economic characterization of an oncology patient and his lifestyle. Measures for improving the system of disease monitoring and cancer registry were developed and implemented. The author presented a substantiation of the organizational model of systemic medical preventive measures for early detection of oncological diseases, and for reducing morbidity and disability. With the participation of the author, 6 methodological recommendations were prepared for implementation in the activities of oncology institutions of Primorsky Krai. The author carried out the planning, generalization, and mathematical-statistical analysis of the research results, calculated the criteria, probable relationships, and prognostic coefficients. A number of mathematical calculations were carried out by programmer specialists of the computing center of Vladivostok using computer programs. The author expresses deep gratitude to the staff of the Primorsky Krai State Sanitary-Epidemiological Surveillance Center, the regional oncology dispensary, Primorgeo, the Institute of Medical Climatology and Rehabilitation, and other institutions where the author conducted research. The author's share in the accumulation of information exceeds 80%, and in the generalization and analysis of the material - up to 100%.

Main provisions for defense:

1. The program and methodology for a comprehensive medical-social and ecological-hygienic study of the influence of natural and anthropogenic risk factors on the formation of oncological pathology among the population. The features of the formation of oncological pathology require a systemic approach and an integrated assessment of the habitat according to specific modules of medical-geographical, medical-social, ecological, and hygienic characteristics, which allow the determination of the class of the ecosystem.

2. Regional medical-geographical and ecological-hygienic features of the Primorsky Krai ecosystem. The increase in oncological morbidity is one of the markers of ecological and socio-hygienic distress on an administrative territory. Results characterizing risk territories are presented.

3. Results of the medical-social assessment of the prevalence of oncological pathology depending on environmental indicators. In the overall characterization of the prevalence of malignant neoplasms in cities, a significant influence is exerted by the module of factors related to anthropogenic impact on the natural environment and the module of factors characterizing the social infrastructure, whereas in the districts of the Krai, the influence of the module of medical-geographical features is pronounced.

4. Indicators of the structure and dynamics of oncological morbidity. A diagnosis of oncological disease is present in 1% of the population of Primorsky Krai. The level of morbidity in the region is characterized by high indicators, and the structure has regional features. In the dynamics, an increase in overall oncological morbidity and mortality is noted. The greatest impact on the reduction of life expectancy is exerted by mortality from lung cancer, stomach cancer, and breast cancer.

5. Prognostic indicators of the spread of oncological pathology on the administrative territories of Primorsky Krai. A probabilistic assessment of the occurrence and spread of oncological pathology, with the calculation of epidemiological risk, indicates unfavorable indicators of the dynamics of morbidity, disability, and mortality in cities and districts classified as critical and tense zones of ecological load.

6. Indicators of medical care for oncology patients. The lack of oncologists in outpatient-polyclinic institutions, insufficient provision with modern diagnostic equipment, the absence of oncological alertness, and prolonged and incomplete examination are often the causes of late diagnosis of malignant neoplasms. Data on the medical-social and economic characterization of oncology patients as consumers of medical services indicate low indicators of their medical awareness and preventive activity.

7. A regional system of prevention of oncological diseases. The effectiveness of the proposed technology for implementing the organizational model for active detection of patients, optimization of the system of accounting for and monitoring oncological morbidity, has been proven.

Structure and volume of the work. The dissertation consists of an introduction, 6 chapters, a conclusion, findings, practical recommendations, a list of references comprising 478 sources (117 foreign), and appendices (with documents confirming the implementation of the obtained results). The main text of the dissertation is presented on 282 pages, contains 25 tables, and 14 figures.