EUGLOREH project




5.3. Cancer

5.3.6 Control tools and policies

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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. Primary prevention


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. Early 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 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 interval).


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:

·          There 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 care.

·          The 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.

·          The 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.

·          The 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.

·          An 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:

·          Further reduce the review time for the marketing authorization of new innovative cancer drugs through the competent authorities.

·          Ensure that once authorization is obtained, the drug is available at national level without further delays due to price and reimbursement negotiations.

·          Ensure that any economic evaluation or Health Technology Assessment (HTA) regarding a new cancer drug is done quickly to facilitate, and not delay, patient access.

·          Ensure 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.

·          There 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 12 years (as increases in costs >5% are often difficult to address with ad hoc budgetary solutions).

·          Although 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.

·          With 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.

·          There 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. Cancer Plans


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):


·          All 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;

·          People 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;

·          Complex interventions for diagnosis or treatment require all the necessary expertise to be assembled and cost-effectively co-ordinated, whilst the results must be consistently monitored;

·          Most 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;

·          Long-term 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






Planning stage


Yes (2003)








Yes (2005)




Yes (regional)




Yes (regional)












Planning stage


Yes (2004)


Yes (regional)








Planning stage






Planning stage









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 entitledResponding 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. Research collaboration


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:


·          Provide proactive leadership in the cancer research community;

·          Be an information exchange portal;

·          Manage networks active in cancer research;

·          Give guidance for transnational, clinical and epidemiological research;

·          Be a “One stop shop” as a contact interface with industry; and

·          Arrange targeted funding for projects that need rapid attention.