5.3.6 Control tools and policies
Cancer control means cancer prevention, diagnosis and
treatment, improving survival and quality of life for cancer patients. This is
achieved by transferring knowledge from research, surveillance, and outcome
monitoring, into strategies and actions (WHO, 2003). The first phase to plan
effective cancer control programmes is finalized to identify priorities. In
this phase, the availability of updated and reliable indicators is essential.
The most obvious ways to prevent people dying from
cancer are in the first instance to find ways to stop the development of
clinical cancer and in the second instance to find cures for the different
forms of the disease. Avoiding exposure to risk determinants would result in a
reduction in cancer risk. Although all of these avoidable causes have not yet
been clearly identified, it is thought that risk determinants currently exist
for about one half of cancers. Thus, primary prevention in the context of
cancer is an important area of public health. The cessation of smoking,
avoidance of harmful alcohol use, diet improvement and physical
activity to avoid obesity, the reduction of over-exposure to
sunlight, and screening for cancer are all recommended by the 2003 European
Code Against Cancer as ways to avoid the disease (Boyle et al, 2003).
See Chapter 10 for primary prevention approaches of
cancer risk factors related to lifestyles or the environment. For further
details see Chapter 4.14.
diagnosis (secondary prevention or screening)
An organised (or mass) screening programme must be seen
as a linked chain of actions, from identification and invitation of the target
population (especially lower socio-economic groups), to a more successful
treatment of cancer patients due to detection at an earlier stage via screening
test. The overall effectiveness of a screening programme is determined by the
weakest link in the chain. Routine evaluation of each step is, therefore,
crucial in order to demonstrate the effectiveness at population level.
Organised screening programmes are likely to be more effective, provide more
equal access and produce less harm and lower costs than spontaneous
(opportunistic) screening. Opportunistic screening should be discouraged. Mass
screening programmes can be more thoroughly evaluated than spontaneous
programmes and, if ineffective, they can be stopped or changed more easily. For
instance, mass screening for neuroblastoma in Japan was shown to be
ineffective, and it was stopped (Tsubono et al, 2004).
Ideally, an organised screening programme should be
prepared making continuous evaluation possible throughout the implementation
phase, including compliance with the invitation, efficiency of referral for
further investigation, sensitivity of the programme and its effectiveness in
reducing cancer mortality. Attention should also be given to informing eligible
persons invited for screening about both the favourable and unfavourable
effects anticipated from screening, so that their choice can be an informed
one. The public health effects of a screening programme, and its costs, should
be carefully predicted before screening is implemented, and the programme
should be continuously evaluated after implementation. The ultimate purpose of
cancer screening is to reduce cancer mortality, and reduce the incidence of the
disease when too advanced for treatment, thus improve the quality of life. The
basic approach is an early detection of disease that is not yet clinically
detectable (Hakama and De Konig, 2007).
Screening has been shown to reduce cancer mortality in
regional comparisons for cervical cancer (with the cervical smear or Pap test),
and in randomised controlled trials for breast cancer (mammography) and
colorectal cancer (faecal occult blood or FOB test). In Europe breast,
colorectal and cervical cancers are the three most frequent cancers amongst
women and colorectal cancer is one of the most frequent cancers also in the
male population. Reductions in mortality of about 25% can be envisaged for
breast and colorectal cancer, and up to 75% for cervical cancer. The situation
of cervical screening in Eastern Europe is one of the major cancer control priorities
to be addressed at European level. Pap smear test is able to detect cervical
anomalies before becoming cancer: this means that effective organised screening
programmes could drastically reduce cervical cancer.
The international scientific community indicates that
organised population-based screening should be promoted for the following
malignancies: mammography for female breast cancer, pap smear for cervical
cancer and faecal occult blood for colorectal cancer. In 2003 the European
Council published recommendations to European Member States for the
implementation of organised screening programmes (European Council, 2003).
Recommendations referred to women aged 25 to 64 for the screening of cervical
pre-cancer lesions (with 3 or 5 years of interval); women aged 50 to 69 for
breast cancer screening (with 2 or 3 years of interval) and men and women aged
50 to 74 for the screening of colorectal cancer (with 1 or 2 years of
It has been shown that indirect or non-experimental
evidence of the efficacy of screening is often misleading, due to a wide range
of biases. Randomised controlled trials are under way in Europe to establish
whether screening for prostate cancer or lung cancer in high-risk subjects may
lead to important health benefits, especially for what concerns a reduction in
mortality. The results of those trials should be awaited before any decision is
made for implementing lung or prostate cancer screening.
Oncologic care and practice
International differences and trends in cancer survival
within Europe are way too large. The geographical patterns and trends in
survival are often broadly consistent with geographical differences or trends
in the type of cancer, diagnostic investigations or overall investment in
health care (Coleman et al, 2003).
Estimating the range of survival rates allows the
identification of regions or countries in which survival could be improved.
There is increasing evidence that international survival differences are at
least partly attributable to factors that are in need of intervention, such as
differences in stage at diagnosis, access to optimal treatment and investment
in health care (Coleman et al, 2003). Therefore, it is fundamental to support
the spread of best practice among European countries and pressure to raise
consistently poor standards.
MOSES-II project performed by ESMO (ESMO, 2006) underlined
that in Europe:
are wide differences in the teaching of oncology (particularly, medical
oncology) and the current situation is still far from being satisfactory,
despite significant progress has been achieved, especially in some countries.
There is still an urgent need to improve teaching in the field of palliative
organization of medical oncology in the different countries is often difficult
to analyze, due to scarce data in some national settings; nevertheless, the
survey showed a lack of homogeneity within Europe and a particular need for
developing palliative care.
rapidly increasing cost of anticancer drugs and devices is an important matter
of concern in many countries. The use of anticancer drugs should be restricted
to specialists in medical oncology.
role of the medical oncologist in the multidisciplinary team is increasing. It
is well recognized in the treatment of several specific tumours in some
nations, but still to be significantly improved in other countries.
increasing number of young medical oncological groups are present in the
national settings, but they must be promptly reinforced, united, and integrated
into the larger medical oncology community.
The report entitled “A global comparison regarding
patient access to cancer drugs” (Jonsson et al, 2007) highlights the inequities
regarding the ability of patients to access new innovative cancer drug
treatments and the importance of equal and rapid access. A number of necessary
actions were identified:
reduce the review time for the marketing authorization of new innovative cancer
drugs through the competent authorities.
that once authorization is obtained, the drug is available at national level
without further delays due to price and reimbursement negotiations.
that any economic evaluation or Health Technology Assessment (HTA) regarding a
new cancer drug is done quickly to facilitate, and not delay, patient access.
that appropriate and adequate funding for new innovative cancer drugs is
available for the health care system and hospital budgets are made on a
proactive rather than on a reactive basis.
is a need for costs and budget impact to be addressed up front. Health care
systems and the pharmaceutical industry must jointly plan for new drug
introductions with a perspective of 1–2 years (as increases in costs >5% are
often difficult to address with ad hoc budgetary solutions).
industry has the capacity to develop new innovative drugs, it comes to the
health care system to integrate these drugs into therapy programs. It is
necessary to gain knowledge about efficacy and toxicity among, for example,
elderly patients, often not included in pivotal trials. It is necessary to
follow long-term toxicity for most of the drugs.
respect to pricing, there are two questions that need to be addressed. First,
it is necessary to move from a national to a global pricing structure and this
will impact accessibility in countries with low purchasing power. Secondly, new
drugs are often launched in a small indication with high medical need (at a
high price), but later its efficacy is shown in major broad indications, with
much larger volumes of sales.
is a need for society to take a long-term perspective on the entire life cycle
of any new drug, including the premium period as well as of the generic phase.
For example, many new drugs have been introduced in the treatment of metastatic
cancer and thus the cost of treatment is rapidly increasing when the drug is
also used in the adjuvant setting. For example, when tamoxifen was introduced,
it was seen as an extremely expensive option while today it is regarded as the
most cost-effective cancer treatment.
Definition of cancer control plan
The cancer burden of a given population is influenced
by interventions of different kinds, from primary prevention of risk factors to
early diagnosis, adequate treatment and end of life care. Organising and
delivering public health programmes designed both to reduce and monitor cancer
incidence with preventive and epidemiological services and improve cancer
outcomes with clinical services is an extremely complex social undertaking,
which involves a wide range of professional expertise and input from
organisations at all levels within the health system.
Cancer control plans (NCPs) are very important tools
through which Competent Authorities in most European countries define, mainly
at national level and in some countries also at regional level, priorities and
main objectives of cancer control for a given timeframe. Obviously, such
planning approach needs to be taken into account together with all available
financial and non-financial resources in order to implement the plan.
The importance of NCP is stressed by scientific
research and patient community (Haward and Borras, 2007):
populations need an effective, integrated cancer plan for primary prevention,
screening, early diagnosis and treatment, as well as research to achieve
long-term reductions in cancer morbidity and mortality;
affected (or suspect to be affected) by cancer need prompt access to
appropriate specialists for accurate diagnosis and subsequent management. A
multidisciplinary approach to cancer care is required to make the best
decisions for each patient’s diagnosis, treatment and support;
interventions for diagnosis or treatment require all the necessary expertise to
be assembled and cost-effectively co-ordinated, whilst the results must be
cancer patients need care for diagnosis and/or treatment at primary, secondary
and tertiary care levels. All parts of the service need to be developed in a
logical manner and effectively communicated;
survivors need special consideration and have specific needs in terms of life
and psychosocial issues that become more relevant when survival increases.
European Union activities on cancer control plans
A number of EU Member States (see Table 5.3.2) consider
national cancer plan as a strategy to manage more effectively the steps to improve cancer control.
Table 5.3.2. Cancer national control plans in place in EU and
year of adoption in 27 EU Member States and other European States in 2007
Source: Haward R, Borras MJ (2007)
Important unexplained variations in service delivery
remain between and within countries in different healthcare settings, which are
often reflected in the quality of care given to individuals. These differences
require research to identify the causes and action to address deficiencies. The
successful implementation of the actions requires sustained collaboration
between national health authorities, research organisation, and stakeholders at
national and European level.
EUROCAN+PLUS aim is to identify best practice components for global cancer
control and areas which could be improved at a national level: identifying
necessary actions at trans-national level is a European added value for each
NCP at a minimal additional cost.
The 2007 Portuguese Presidency of the EU, during a
Parallel Session on Cancer as part of its Health Strategies in Europe conference, stressed that strategic action is required in most EU Member States to
develop or improve national cancer plans, comprehensive cancer control
programmes and population-based cancer registries, all of which will play a
fundamental role in cancer control. Slovenia, who took over the chair of the EU
Council in January 2008, has named cancer as one of its top priorities in the
field of health, and promoted the adoption of Council Conclusion on “Reducing
the Burden of Cancer” that provides clear indications on a number of tools and
initiatives that would be very beneficial for fighting cancer. The book
entitled “Responding to the Challenge of Cancer in Europe”, has been produced
as a collaboration between internationally recognised public health institutes
in the EU, under the Fighting Against Cancer Today (FACT) umbrella.
A Declaration of the European Parliament (October 2007)
calls on the Council and Commission to formulate a comprehensive strategy
addressing four basic cancer control factors: prevention, early detection,
diagnosis, treatment and follow-up, and palliative care. The Parliament’s
health committee has now called on the Commission to set up a EU Cancer Task
Force to provide leadership for cancer control activities in Europe.
Cancer research in Europe is of a high standard, but
fragmentation and lack of sustainability remain the largest barriers in
implementing innovation into cancer care.
Eurocan+Plus involves almost 300 participants from
throughout the EU, many of whom are leaders in their respective area of
expertise. Eurocan+Plus identified the main barriers to collaboration and the
areas that would most benefit from coordination. The project suggests the
formation of a light but permanent European Cancer Initiative, which will
mainly serve to:
proactive leadership in the cancer research community;
an information exchange portal;
networks active in cancer research;
guidance for transnational, clinical and epidemiological research;
“One stop shop” as a contact interface with industry; and
targeted funding for projects that need rapid attention.