Opinion on the proposal for a European Parliament and Council Decision adopting an action plan 1995-1999 to combat cancer within the framework for action in the field of public health () (94/C 393/03)

On 13 July 1994 the Council decided to consult the Economic and Social Committee, under Article 129 of the Treaty establishing the European Community, on the abovementioned proposal.

The Section for Protection of the Environment, Public Health and Consumer Affairs, which was responsible for preparing the Committee's work on the subject, adopted its Opinion on 5 September 1994. The Rapporteur was Mr Colombo.

At its 318th Plenary Session (meeting of 14 September 1994), the Economic and Social Committee adopted the following Opinion unanimously.

1. Introduction

1.1. The Committee approves the proposal to adopt a new programme which falls within the wider dimension of Community public health policy, and also takes account of the track record of the preceding programmes (1987-89 and 1990-94).

1.2. The evaluation report on the first six years of the programme was approved on 15 March 1993 and was forwarded to the Economic and Social Committee as well as to the Council and European Parliament. It showed that the Community has a specific role to play and can bring an added European value to national actions by creating synergies which allow significant economies of scale.

1.3. The significant results achieved, and the success of other action plans such as the one against AIDS, have led to an extension of Community initiatives in the public health sphere, culminating with its enshrinement in Article 129 of the Treaty. For a consideration of the interpretation to be given to that Article, and more especially to the concept of 'prevention', the Committee would refer to its Opinion on the Commission Communication on the framework for action in the field of public health ().

1.4. It is useful to examine the contents of the new action plan in the light of this new approach, having regard to the importance of improving public health and quality of life in the EU.

2. Justification and content of the new action plan

2.1. The most recent data (1990) indicate an annual incidence of 1.3 million new cases of cancer and 840,000 deaths from cancer each year in the European Union. Cancers are responsible for about a quarter of all deaths in the EU, with relatively minor variations from country to country and relatively more cancer deaths in the northern Member States than in those of the South. Over recent decades, cancer deaths in the EU have risen sharply because of the progressive ageing of the population.

2.2. The mortality rate remains higher for men than for women in all Member States, the difference being particularly marked in some of them. In the EU as a whole, women are 40 % less likely to die from cancer than men. The higher incidence of male morbidity and mortality is mainly attributable to their heavier consumption of tobacco and alcohol, but also to occupational exposure to carcinogens and biological differences between the two sexes. The wider availability of early mass screening could also explain the lower female morbidity and mortality rates.

2.3. Available data show that 30 % of cancer deaths are due to tobacco, 3 % to 10 % (depending on country) are due to alcohol, and around 30 % are linked to diet. This means that over two thirds of deaths from cancer are linked to lifestyles and therefore might be avoided by a change in behaviour.

2.4. The Commission's Communication on the framework for action in the field of public health [COM(93) 559 final] proposes four objectives for Community action. The 'Europe against cancer' programme must address all of them:

- to prevent premature death which particularly affects the young and the working population;

- to increase life expectancy without disability or sickness;

- to promote the quality of life by improving general health and the avoidance of chronic and disabling conditions;

- to promote general well being of the population, particularly by minimizing the economic and social consequences of ill health.

2.5. Community action will focus on encouraging cooperation between Member States, lending support to their action and promoting coordination of their policies and programmes.

3. General comments

3.1.

Financial allocation

3.1.1. As in the past, but all the more so in the light of Article 129, the Committee is concerned at the limited financial resources earmarked for the action plan (MECU 64).

3.1.2. The modest level of funding is in marked contrast to the scale of Community support for tobacco producers. The Committee expresses its disquiet at this in point 3.4.3.

3.1.3. It we look at the actual sums allocated to research and prevention, and to improvements in patient-care, then the low level of the proposed funding becomes even more obvious. The action plan should avoid a scattergun approach and concentrate on synergies. Priority status should be given to developing concrete prevention measures, and improving the quality of treatment.

3.2.

Consultation and participation mechanisms

3.2.1. Under Article 5 of the proposal, the Commission is to be assisted by an advisory committee. Point 93 of the accompanying Communication states that this is to consist of representatives of the Member States, health professionals and non-governmental organizations in the field. The Committee recommends that there should also be adequate representation of socio-economic, consumer and environmental organizations, as these have already shown that they can make an important contribution to information and prevention campaigns.

3.2.2. Given the wide scope of the action against cancer and the many links with other aspects of public health, the Committee stresses the need to involve as many interested parties as possible (see Points 95, 96 and 97 of the Communication). European 'added value' is gained inter alia by comparing notes and by synergies between the various parties on the national coordinating committees.

3.2.3. The Committee is pleased to see the Commission's undertaking (Article 7) to send it the annual report on the progress of the action plan and on the financing of the various fields of action. As well as helping to make matters more open, this will provide an opportunity to assess the results and added value obtained, and to steadily sharpen the focus and hence effectiveness.

3.3.

Biomedical and health research

3.3.1. The Committee notes the reference (Article 4) to complementarity between the actions of the present plan and the biomedical and health research programme under the Framework Programme.

3.3.2. The Committee stresses the special importance of synergies in the research field, particularly in genetic research. The establishment of a good network of cancer registers now makes it possible to compare the epidemiological situation in most Member States (see Point 5 of the Communication) and improve the targeting of research efforts.

3.3.3. The Committee would like to see closer cooperation between the two Directorates General concerned (health and research), so as to speed up and simplify funding procedures, subject to the appropriate guarantees and vetting.

3.4.

Relations between public health policy and other policies

3.4.1. The Committee sets great store by the third paragraph of Article 129(1):

'Health protection requirements shall form a constituent part of the Community's other policies.'

3.4.2. This is particularly true of the prevention of a disease such as cancer, which is largely related to lifestyle, diet, quality of the environment in general, and quality of the workplace environment.

3.4.3. Accordingly, the Committee recommends that the Commission check that other Community policies are consistent with the objectives of the action plan against cancer. For example, this is not the first time that the Committee has to lament the blatant contradiction between the anti-smoking campaign and the Community funding of tobacco producers.

3.4.4. The Committee thus welcomes the Commission's intention, voiced in Point 38 of the Communication, to submit a yearly report on the health protection aspects of policies and include it in the Annual Report of the Commission.

3.4.5. Particular attention should be paid to the link between agricultural policy, consumer protection and an improvement in eating habits (encouraging the public to eat more fruit and vegetables and alerting them to the dangers of excessive dietary intake of animal fats).

3.4.6. Another feature is the link between environmental policy and health policy. The increase in malignant melanomas caused by exposure to the sun not only demands more public information, but also more decisive Community action to protect the ozone layer, as the Committee has already pointed out elsewhere ().

4. General comments on the specific actions

4.1. The Committee endorses the objectives set out in Chapter V of the Communication, as well as the choice of priority actions.

4.2. However, the Committee considers that insufficient stress is laid on the relation between cancer and environmental pollution. It asks the Commission to examine this, particularly in its research programmes.

4.3. The Committee notes that the spotlight is still on action against smoking, with targeted campaigns and specific measures on which it has already taken a stand (). The Committee is also pleased to see that other aspects of prevention, notably diet, are now starting to receive more attention.

4.4. The Committee feels that information campaigns should be better targeted on specific groups and should have a more cogent message, since this has to compete with contradicting advertising slogans. The aim should be to persuade rather than to intimidate.

4.5. Special importance should be accorded to epidemiological surveys, as these provide a good way of monitoring the disease. Registration systems need to be improved, and the collection of reliable data should be harmonized. By guaranteeing anonymity, personal () data protection rules need not interfere with health research needs.

5. Specific comments on the individual actions ()

5.1.

Cancer registries and epidemiological studies

5.1.1. The provision of cancer registries is vital for collecting and disseminating reliable, comparable epidemiological data. It is a vital part of any anti-cancer programme. The official recognition of effective cancer registries in Europe began in 1989 with the setting-up of the European network of cancer registries (), and should help to identify areas which are not yet covered.

Among issues to be addressed by Member States in accordance with the subsidiarity principle, the following should receive the utmost priority:

a)

the establishment of population registers in parts of the Community which lack them;

b)

improvement of registers with insufficient logistic or organizational back-up, more especially through the provision of financial support and vocational training;

c)

strengthening of links between the European registries, to further the declared aims of the European registry network (already accorded top priority in Commission programmes).

5.1.2. Europe's wide variety of geographical features and populations make it an interesting test-bed for epidemiological research. Priority support should be given to site-specific epidemiological studies of Community interest, not only for the purpose of fostering cooperation. In particular, the collection and analysis of epidemiological data on rare or low-incidence cancers offer a golden opportunity to gather information which would be difficult to obtain individually. The establishment of biological materials banks open to European researchers in the various sectors of oncology would also encourage the coordination of research and permit significant economies of scale.

5.2.

Prevention

5.2.1.

The preventive role of health education

5.2.1.1. Proper health education for the population is a prerequisite of any cancer prevention programme. Action should focus on the following:

1. Organization of information campaigns coordinated at least at regional level with action in schools, general practices and local health centres. The information should highlight:

a) the dangers of smoking, with campaigns to persuade smokers to give up;

b) the dangers of excessive alcohol consumption and a fatty diet, with general guidance on healthy eating;

c) for women: advice on feminine hygiene and the need for regular gynaecological check-ups and breast examinations;

d) the risks of excessive exposure to the sun, in connection with skin cancer prevention;

e) for men: advice on personal hygiene and the need for self-examination and regular medical check-ups.

Account should also be taken of European demographic trends and the steady ageing of the population, as it is particularly important to gear information programmes to the target population in both technical/logistical and psychological terms.

2. Training and refresher courses for doctors and other health professionals in hospitals and elsewhere (group practices and local health centres, family practitioners). Here it is important to stress the positive impact which preventive campaigns could have on the monitoring and identification of high-risk groups.

3. Appropriate support for the further training and exchange of health professionals working at specialist cancer centres in the Community. Such support should also cover centres which have not yet achieved a high level of performance.

5.2.1.2. In the field of cancer health education, we should emphasize the need for a proper geographical distribution throughout the Community of specialist oncology schools providing further training for nursing staff. Specialist nursing is a vital part of proper patient care, and the present situation in many areas of the Community is far from satisfactory.

5.2.1.3. The identification of cancer reference centres (among cancer institutes, teaching hospitals and general hospitals) has not been completed everywhere in Europe and in some Member States has not even begun. Member States should be strongly encouraged to rectify this state of affairs, so that a brochure can be issued for distribution throughout the Community, listing such centres and giving details of how they are organized and whether they have any particular specialisms.

5.2.1.4. Given the increasing media role in the dissemination of health information, it is important to stress that improper use of the media can lead to the distortion of information. This is of particular significance where cancers are concerned. It is therefore desirable that authoritative watchdogs be set up in all Member States to monitor scientific information sources. To this end, a European agency of cancer specialists and media experts could be set up in order to draw up regular information leaflets for distribution throughout the Community. The circulation of such information could be entrusted to the health education institutes of the Member States.

5.2.2.

Secondary and tertiary prevention

5.2.2.1. If precancerous lesions and tissue damage are diagnosed at an early stage and treated promptly, they can very often be cured - the World Health Organization estimates that the success rate may be as high as 85 %. In order to enhance the potential value of secondary and tertiary prevention programmes, the population need to be better informed, the skills of health professionals need to be updated, and public health bodies should show greater sensitivity and better organization.

5.2.2.2. Screening programmes for cervical cancer have significantly reduced the number of cervical cancer deaths in many countries. The encouraging results of mammography-based breast-screening programmes have prepared the ground for national screening programmes, as have recently been undertaken in the UK. Screening programmes for lung cancer have been somewhat disappointing, in contrast to the encouraging preliminary data emerging from the screening trials currently under way for cancers of the colon and rectum, ovaries and prostate and child neuroblastoma.

Community actions should therefore give priority to programmes for early diagnosis of the following cancers, for which a positive cost-benefit ratio may reasonably be expected.

1) cervical cancer;

2) breast cancer;

3) colorectal cancer;

4) ovarian cancer;

5) prostate cancer;

6) child neuroblastoma.

Screening programmes for cervical cancer and breast cancer have already proved their worth, and there are also valid grounds for encouraging further action on the other four.

5.2.2.3. For screening to be as effective as possible, it is vital to target risk groups. Current early diagnosis methods are costly and may not be widely available (e.g. ultrasound for ovarian cancer, coloscopy for colorectal cancer). This makes it all the more necessary to select likely groups for screening. This is particularly important when screening for cancers which may involve a hereditary factor (e.g. ovarian cancer, breast cancer, colorectal cancer).

Priority should therefore be given to screening programmes (for cancers other than cervical cancer - notably ovarian, breast and colorectal cancer) which base their selection criteria on family research. Such programmes may be conducted on a national and/or European basis and will at all events gain a high added value through cooperation. They would also provide an opportunity to set up biological materials banks with material from high-risk groups.

5.2.2.4. More generally, priority should be given to actions where significant economies of scale can be achieved by simultaneous screening for several cancers (made possible by shared characteristics of the target population, diagnostic methods and logistical organization). Screening programmes for women are one example; another more obvious one is schemes targeted at family groups with a risk of various adenocarcinomas (see Point 2.3.3).

5.3.

Quality of care

5.3.1. With a view to improving the quality of cancer care, the following actions should receive priority:

a)

studies of the clinical significance of stepping up chemotherapy dosage when the preliminary stage of chemotherapy has proved beneficial. Particular support should be given to studies which, as well as being of clinical or therapeutic interest, entail important bio-technological innovations in support therapies;

b)

combined analyses, by reprocessing data from controlled clinical studies, to obtain information that is not clear from individual studies;

c)

clinical studies of the use of new drugs and/or new therapeutic combinations. Here we should stress the value of increasingly close cooperation between pharmaceutical and clinical researchers in specialist cancer centres.

5.4.

Research activities

5.4.1. Community research initiatives, and particularly the BIOMED programme, should concentrate on the molecular features of tumours. Particular consideration should be given to the study of tumours of family origin which can provide a valid model, so that the information obtained can be transferred to sporadic tumours. Here encouragement should go to the establishment of tumour tissue banks, run on a cooperative basis and available to interested bodies.

Among studies aimed at improving the molecular characterization of tumours, priority should go to those whose results can be useful for the following:

5.4.1.1. Identification of people with a high genetic risk of cancer. Certain molecular alterations have been identified in families with a high incidence of cancer. Further study may soon make it possible to identify individuals at high genetic risk by means of a blood test. Hence it is clearly important to encourage cooperation between epidemiologists, geneticists and molecular biologists in order to plan molecular epidemiology studies.

5.4.1.2. Improvement of prognoses for tumours, in order to plan treatment more effectively. This is important in order to identify patients with highly aggressive tumours which will need further adjuvant treatment after the primary treatment. Moreover, it is not currently possible to make an accurate prognosis simply on the basis of the clinical or pathological characteristics of a tumour. Molecular biology studies could prove crucial here, as they would provide a way of identifying molecular changes of significance for the likely development of the tumour.

5.4.1.3. Formulation and implementation of anti-tumour gene therapies to correct genetic defects in the tumour or to prevent the activation of oncogenes (proteins which, when transformed or produced in abnormal quantities, may lead to the formation of a tumour).

5.4.1.4. Trials of new forms of immunotherapy, based on active immunization of the patient or using cells from the patient transfected with genes by cytokines. Particular attention should focus on the preparation of 'anti-cancer vaccines' which use tumour extracts and are designed to strengthen the patient's immunological defences. Support should thus also be given to research into the interaction between patient and tumour, in order to gain a clearer picture of the immunological, hormonal and environmental aspects which may encourage the onset and spread of a cancer.

Done at Brussels, 14 September 1994.

The President

of the Economic and Social Committee

Susanne TIEMANN

() OJ No C 139, 21. 5. 1994, p. 12.

() OJ No C 295, 22. 10. 1994.

() OJ No C 52, 19. 2. 1994.

() See OJ No C 159, 26. 6. 1989, concerning the ban on smoking in public places, and OJ No C 62, 12. 3. 1990 and C 313, 30. 11. 1992, concerning advertising of tobacco products.

() See Proposal for a Council Directive concerning the protection of individuals in relation to the processing of personal data, OJ No C 277, 5. 11. 1990 and the Opinion of the Committee in OJ No C 159, 17. 6. 1991.

() Section 5, drawn up with the help of Professor Mancuso of the Università Cattolica del Sacro Cuore, suggests a number of measures which could be taken under the programme, bearing in mind the general considerations outlined above.

() European Network of Cancer Registries; an initiative by I.A.R.C., The Danish Cancer Registry, I.A.C.R., The Latin Language Registry Group in the framework of the EAC programme. Acting Director: H.H. Storm, Danish Cancer Society, Copenhagen, Denmark.