[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 24.6.2009

COM(2009) 291 final

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS

on Action Against Cancer: European Partnership

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS

on Action Against Cancer: European Partnership

1. WHY A PARTNERSHIP FOR ACTION AGAINST CANCER?

Despite the progress in recent times, cancer still takes an enormous toll on European society. After circulatory diseases, cancer was the second most common cause of death in 2006, accounting for two out of ten deaths in women and three out of ten deaths in men, equating to approximately 3.2 million EU citizens diagnosed with cancer each year.

The legal basis for action in the field of health largely falls on the Member States (Article 152 of the EC Treaty). However, as underlined by the Health Strategy 'Together for Health: A Strategic Approach for the EU 2008-2013', there are areas where joint EU action can bring considerable added value in tackling major health challenges more effectively, through information sharing, and exchange of expertise and best practice[1].

The European Parliament and Council of the European Union have also shown their political commitment and given strategic direction to future European cancer activities. On 10 April 2008, the European Parliament adopted a resolution on combating cancer in the enlarged EU, and Council conclusions on reducing the European burden of cancer were adopted on 10 June 2008[2], [3].

On this basis, the European Commission proposes a European Partnership for Action Against Cancer for the period 2009-2013 to support the Member State in their efforts to tackle cancer by providing a framework for identifying and sharing information, capacity and expertise in cancer prevention and control, and by engaging relevant stakeholders across the European Union in a collective effort. As demonstrated by the existing stark differences and inequalities in cancer incidence and mortality throughout the Community, there is considerable added value in working together on a European level to prevent and control cancer more effectively.

This Communication broadly sets out the objectives for the European Partnership for Action Against Cancer, the identified areas and actions to be further determined and taken forward through a European partnership approach, the proposed structure of the Partnership and the anticipated next steps.

1.1. Cancer: a model for application of the principles of the Health Strategy

As cancer is one of the major causes of ill health in the European Union, associated with a considerable cost to society, it is essential to invest in Europe’s future health by taking long-term and sustainable actions to tackle cancer. In 2005 alone, it was estimated that over 17 million disability-adjusted life-years were lost because of cancer in the WHO European region. However, to tackle effectively the wide range of health determinants associated with cancer, we also need to move beyond the health area, and adopt a cross-sectional approach, integrating health into policy areas such as education, environment, taxation, research, and social and external affairs.

1.2. Importance of addressing cancer in order to maximise years of life in good health

Considering the socio-economic implications of the expected rise of cancer as the European population ages, it is vital to tackle this disease more effectively in the EU. For example, effective prevention can greatly contribute to improving health. It has been predicted that by implementing 100% population coverage of cervical cancer screening, an estimated reduction of over 94% of life years lost could be attained, and for every 152 pap smear tests performed, one life-year could be gained. In these times of financial instability, it is all the more important to maintain investments in health, in particular through such preventive actions.

The Healthy Life Years indicator is a measure used by the Commission to assess the number of remaining years that a person of a certain age is expected to live disability-free, and is used to monitor health as a factor in productivity and economic prosperity to support health promotion policies.

1.3. Collective response – European Partnership for Action Against Cancer

To more effectively coordinate activities and actions that are taken within different policy areas by Member States and other stakeholders, with the aim of reducing the increasing and unequal European burden of cancer, the European Commission proposes a European Partnership for Action Against Cancer for the period 2009-2013 .

As indicated above, this Partnership aims to support the Member States in their efforts to tackle cancer by providing a framework for identifying and sharing information, capacity and expertise in cancer prevention and control, and by engaging relevant stakeholders across the European Union in a collective effort to address cancer. As illustrated by the national and regional differences in cancer incidence and mortality, there is considerable scope for reducing the European burden of cancer through a joint response, guided by evidence-based strategies for disease prevention and control. This partnership approach will help to avoid scattered actions and the duplication of efforts. It will also contribute to the better use of the limited resources available.

By the end of the Partnership, the objective is for all Member States to have integrated cancer plans. The Commission considers that putting such plans in place should make a sustainable contribution to reducing the burden of cancer in the EU, and that the target of a 15% reduction by 2020 (510 000 new cases) is an achievable result.

2. COMPREHENSIVE POLICY RESPONSE: AREAS AND ACTIONS

2.1. One third of cancers are preventable – the most cost-effective response

Health promotion

A horizontal approach on the basis of tackling major health determinants is essential to curb the increasing burden of cancer throughout the European Union. Cancer is caused by many factors and therefore its prevention shall address on equal footing the lifestyle, occupational and environmental causes. It has been estimated that around one third of all cancers could be prevented by modifying or avoiding key risk factors such as smoking, being overweight, low fruit and vegetable intake, physical inactivity and alcohol consumption.

Health promotion on the basis of major health determinants has been a longstanding priority for the European Commission, and has included strategies for nutrition, overweight and obesity-related health issues, and support for alcohol-related harm. The Commission has also adopted an ambitious tobacco control policy aimed at discouraging children and young people from taking up smoking, supporting smoking cessation and protecting all citizens against exposure to second-hand smoke, taking into account the need to tailor health promotion to specific population and target groups.

Other key determinants are occupational and environmental factors, such as exposure to carcinogenic and mutagenic substances, and indoor and outdoor air quality. The World Cancer Report 2008 by the International Agency for Research on Cancer (IARC) highlights the importance of primary environmental prevention and exposure reduction. Implementation of existing legislation and the development of new legislation related to general chemical exposure[4], i.e. in water, waste and through persistent organic pollutants, thus contribute to cancer incidence prevention. In order to more effectively tackle the health impacts of such environmental factors and to foster cooperation, the Commission has adopted a European Environment and Health Action Plan. Moreover, Directive 2004/37/EC sets out a number of preventive measures to eliminate or minimise work-related exposures to carcinogens and mutagens[5]. The list of carcinogens and mutagens is being updated in line with scientific evidence.

Among the specific cancer prevention activities that have proven to be successful is the European Code Against Cancer[6]. It gives two very clear messages:

- certain cancers may be avoided – and health in general can be improved – by adopting healthier lifestyles; and

- cancers may be cured, or the prospects of cure greatly increased, if they are detected at an early stage.

Early detection

Cancer can be reduced and controlled by implementing evidence-based strategies for early detection and management of patients with cancer. This includes appropriate information to ensure awareness about the benefits of screening for those who should benefit from it. This is an area where Community added value has already proven to be efficient in supporting Member States' development of screening programmes for breast, cervical and colorectal cancer.

Despite these substantial efforts, the volume of screening examinations in the EU is less than half of the minimum annual number of examinations that would be expected if the screening tests specified in the Council Recommendation on cancer screening were available to all EU citizens of appropriate age (approximately 125 million examinations per year)[7], [8].

Alternative preventative approaches against infectious agents that can cause cancer, such as high-risk human papillomavirus (HPV) with particular impact for young women, should also be further examined. The European Centre for Disease Prevention and Control has published "Guidance for the introduction of HPV vaccines in EU countries", which lays down the scientific basis for the potential introduction of HPV vaccines.

Objectives for action : to reduce the burden of cancer by achieving 100% population coverage of screening for breast, cervical and colorectal[9] cancer as set out in the Council Recommendation on cancer screening by 2013; providing 125 million examinations to citizens per year. In order to achieve this target Member States should promote large scale information campaigns on cancer screening, directed at the general public and health-care providers.

Other actions could include:

- Assessing the effectiveness of Community policy in the area of tobacco control;

- Using existing mechanisms, such as the stakeholder forums focusing on alcohol and nutrition, to take forward cancer actions;

- Reviewing the European Code Against Cancer, including its implementation;

- Assessing the burden of infection-induced cancer in the EU;

- Providing an overview of the range of recommendations in the EU on the implementation of human papillomavirus vaccination as a public health policy to prevent cervical cancer;

- Reviewing the Council Recommendation on cancer screening in view of recent scientific developments, and the obstacles that Member States are facing in the implementation of breast, cervical and colorectal cancer screening programmes;

- Development of a voluntary European pilot accreditation scheme for breast cancer screening and follow-up, building on the European guidelines for quality assurance in breast cancer screening and diagnosis as the most longstanding and developed guidelines in the area.

2.2. Applying best healthcare approaches in practice - identification and dissemination of good practice

A comprehensive cancer approach and multidisciplinary teams can ensure more effective care for patients with cancer. For example, the fourth edition of the European guidelines for quality assurance in breast cancer screening and diagnosis includes a detailed framework for establishing and running effective specialist units for breast cancer treatment and care. Integrated cancer care, giving due consideration to psychosocial wellbeing and support, is a vital part of care that also should be encouraged. In addition to strictly curative care, there is an increasing need to focus on the quality of life for a rising number of chronic cancer patients whose illness cannot be cured but may be stabilised for a number of years. Finally, palliative care for terminally ill cancer patients also varies in quality between Member States and can benefit from exchange of good practices.

Another area of EU added-value would be cooperation on European Reference Networks, for example in the field of rare diseases, which include many rare cancers. European Reference Networks provided for in the Proposal for a Directive of the European Parliament and of the Council on the Application of Patients' Rights in Cross-border Healthcare should provide healthcare to all patients who have conditions requiring a particular concentration of resources or expertise in order to provide affordable, high-quality and cost-effective care, and can also be focal points for medical training and research, information dissemination and evaluation.

Objectives for action : to tackle inequalities in cancer mortality amenable to healthcare by reducing the disparity between the best and worst performing Member States. Whilst it may not be possible to eliminate all the existing inequalities, the Commission considers that a 70% reduction by 2020 is a feasible target, taking account of scientific developments and the different circumstances of different countries and cancers. This aim will be supported by the development of guidelines for models of best practice in cancer-related care, taking into account national, regional and local contexts.

Other actions could include:

- Sharing knowledge and expertise on different models for comprehensive and integrated cancer care, and in particular the organisation of care, with the aim of developing consensus around definitions and models of care, including chronic and palliative care;

- Exploring the application of ongoing European efforts under the Health Technology Assessment initiative as a means to tackle cancer more efficiently, building on the framework to be established under the proposed Directive on the Application of Patients' Rights in Cross-border Healthcare;

- Exploring alternative technical and financial solutions for the European supply of medical isotopes, taking account of shortages in supply across Europe.

2.3. Cooperation and coordination in cancer research

A comprehensive cancer approach should include all aspects of cancer research, ranging from prevention to translational and clinical research. Health research is of central importance to the EU's research commitments. During the 6th Framework Programme for Research and Technological Development and in the first two calls of the 7th Framework Programme, about €750 million has been devoted to cancer research, covering all major types of cancer and involving a wide range of actors, such as academia, small and medium-sized enterprises, and large industrial partners.

Recognising that cancer research is mainly undertaken at national level and that it is considerably fragmented and diverse across the EU, the Community aims to step up its efforts to improve EU-wide coordination within this field, in line with the European Research Area's objectives. In addition, elements such as the Innovative Medicine Initiative (IMI) and ESFRI (European Roadmap, which includes also research infrastructures for clinical trials and biomedical research), which will benefit cancer research, are being introduced. IMI is a pan-European public and private sector collaboration endeavouring to support the discovery and development of better medicines, including cancer therapies, and the ESFRI Roadmap includes projects to support the establishment of clinical trials facilities and bio-banking to pave the way for a more harmonised European framework. In this context, it is also important to highlight that a European Clinical Trials Directive was adopted in 2001, providing a standardised European framework for the implementation of good practice in the conduct of clinical trials on medicinal products for human use[10].

Objectives for action : to develop a coordinated approach to cancer research across the EU, aiming to achieve coordination of one third of research from all funding sources by 2013.

Other actions could include:

- Identification of discrepancies, and bringing together partners in a collective effort to address obstacles in European cancer research;

- Identification of gaps in research and methodology, enhancement of research cooperation to avoid duplication of efforts and strengthening research on prevention and translational research;

- Strengthening of public access to information on cancer research and clinical trials in particular;

- In order to further improve the regulatory environment on clinical research in the EU, the Commission will assess the application of the Clinical Trials Directive10 with a view to making, if appropriate, legislative proposals.

2.4. Benchmarking process – providing the comparable information necessary for policy and action

A cancer information system is important to ensure comprehensive and standardised cancer information and data from all Member States. The collection of data and information enables, mainly through cross-national comparisons, the identification and promotion of evidence-based best practice in cancer prevention and control. These European comparisons have in the past brought to light considerable differences in cancer survival in the EU between countries with similar levels of wealth and health care provision. As a result, a number of Member States, which reported relatively high cancer mortality in the early 1990s have reviewed and subsequently reformed their national cancer policies, and are today reporting improved cancer survival. By developing a European benchmark for best practice, there is in other words considerable scope for addressing health inequalities. Thus, sharing relevant information for statistical purposes is essential for developing effective public health interventions and the European benchmarking process. Appropriate data collection and analysis techniques should be used, e.g. anonymisation, in accordance with existing legislation on the protection of personal data[11].

The major role in a cancer information system is played by national and regional population-based cancer registries that collect and analyse data on cancer in the Member States. The invaluable contribution of these registries represents just a fraction of the total EU spending on cancer. For example, the proportion of national spending on cancer registries in Finland in 2007 was only 0.0037% of total spending on cancer, illustrating the cost-effectiveness of this small investment to provide the data necessary for effective policies.

Objectives for action : to ensure accurate and comparable data on cancer incidence, prevalence, morbidity, cure, survival and mortality in the EU by 2013.

Other actions could include:

- Identification of obstacles in collection of data and indicators, including legislative obstacles and accessibility of data, and ways to overcome those problems;

- Agreement on a set of core indicators to measure and enable European comparisons of the burden of cancer, quality of care and impact of cancer strategies, with special emphasis on health inequalities;

- Encouragement of high quality standards and networking on cancer registries;

- Collection of data on the cost of cancer to society;

- Conducting a survey to gauge European opinion on cancer data registration as a means for public health research and planning of effective health systems.

3. SUSTAINABLE ACTION IN TACKLING CANCER - WORKING TOGETHER IN PARTNERSHIP

In accordance with Article 152 of the EC Treaty and the principle of subsidiarity, the European Partnership for Action Against Cancer will focus on actions that can be taken at EU level to more efficiently prevent and control cancer. Based on a cooperative and action-based approach, this joint Partnership will bring together a wide range of actors at EU level, including Member States, experts, health care professionals, NGOs, patient groups, civil society representatives and industry, as a model for non-communicable diseases in general.

The Partnership will provide a platform for analysing the present cancer burden and trends, national strategies for cancer prevention and control, insufficiencies and discrepancies, and desired objectives for future cancer action at EU level. Through the exchange of information, expertise and best practice, the Partnership will contribute to reducing inequalities in health by assisting underperforming Member States to more efficiently prevent and control cancer. Moreover, European activities in health promotion relating to cancer, such as tobacco, nutrition, physical activity and environment efforts, will primarily be addressed through existing mechanisms, including the EU Platform for Action on Diet, Physical Activity and Health and the Alcohol and Health Forum, rather than the Partnership itself. The Partnership will act in complementary areas to ensure a comprehensive and coherent approach to cancer at EU level.

In order to take forward these identified areas and actions, this Communication proposes a specific joint action to be supported by the Health Programme as from 2010[12]. The work of the Partnership is proposed to be undertaken in multi-stakeholder working groups (based on the four areas of action in section two), which will either undertake the identified areas of work directly or monitor work to be conducted by outside actors, institutions or organisations, as appropriate. It is proposed that the activities of the stakeholder working groups be coordinated by a steering group, which will report to the Partnership secretariat and the open forum, which will be held once a year. In addition, through the Health Programme, the Commission aims to provide additional technical support, including administrative and scientific support, to the stakeholder working groups (Figure 1). The yearly open forum aims to provide a platform for the members of the Partnership and other stakeholders at EU level to deepen their understanding of the challenge of cancer for European society, and to identify where common action can bring added value to national efforts in combating the burden of cancer.

The role of the European Commission will be to ensure the cooperative and action-oriented approach of the Partnership, and to make certain that the proposed actions and activities are appropriate for action at EU level.

Figure 1 [pic]

3.1. Next steps

The Partnership is planned to be launched in the third quarter of 2009.

The Partnership aims to bring together European stakeholders with a common aim and commitment to reduce cancer. To ensure equal and fair representation, all stakeholders whose objectives fall in line with the overarching aim of the Partnership are in principle welcome to join the initiative. However, in order to obtain balanced stakeholder representation, members representing a specific organisation, interest area or industry shall as far as possible be represented by umbrella organisations operating at European level, as well as being capable and willing to play an active role in reducing the European burden of cancer. Stakeholders who are represented by an umbrella organisation are also welcome to join the Partnership, but will participate under the aegis of their organisation.

This Communication broadly defines the objectives for European action against cancer whilst the aim of the Partnership is to determine specific key activities and actions to prevent and control cancer through the above presented approach. This also includes regular monitoring and evaluation of the work undertaken by the initiative. The steering group will, however, be requested to report to the Partnership secretariat and the open forum on an annual basis. The Partnership secretariat will also be required to submit interim and final implementation reports to the Executive Agency for Health and Consumers (EAHC) in accordance with procedures and conditions applicable to joint actions. In addition, to ensure transparency and accountability, the outlined objectives and outcomes of the Partnership will be presented on a separate website. This website, the so-called Virtual Partnership, will provide an extensive overview of the initiatives and work undertaken by the Partnership. The website should be part of a wider communication strategy to ensure dissemination throughout the Community.

At the end of the current financial framework, a review process will be undertaken to assess the Partnership's successes and shortcomings. A final report on the work undertaken on the basis of this Communication will be submitted by the Commission to the Council of the European Union and the European Parliament, which will constitute the basis for determining future Community action on cancer.

3.2. Funding

The Partnership's actions will be supported by existing financial instruments until the end of the current financial framework (2013), without additional budgetary consequences. The annual work plans of the second programme of Community action in the field of health will be a key instrument in supporting this strategic Partnership. In addition, several other Community programmes also provide funding relevant to cancer, e.g. the 7th Framework Programme for Research and Technological Development as well as Regional Policy Programmes.

4. CONCLUSION

Cancer affects a growing number of individuals and their relatives and represents an enormous burden on society in an ageing Europe. As demonstrated by previous activities, such as the Europe against Cancer Programmes and within the Health Programmes, European action in the field of cancer can bring considerable added value in tackling more efficiently the burden of the disease on a national, regional as well as local level throughout the Community. The European Commission proposes to build on these efforts through a sustainable action, following a partnership approach, involving a wide range of stakeholders working together in the fight against cancer.

[1] Together for Health: A Strategic Approach for the EU 2008-2013 - COM(2007) 630.

[2] European Parliament Resolution of 10 April 2008 on Combating Cancer in the Enlarged European Union, P6-TA(2008)0121.

[3] Council of the European Union, Council Conclusions on Reducing the Burden of Cancer, 2876th Employment, Social Policy, Health and Consumers Affairs Council Meeting, Luxembourg, 10 June 2008.

[4] Regulation (EC) No 1907/2006 of the European Parliament and of the Council of 18 December 2006 Concerning the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH), Establishing a European Chemicals Agency, Amending Directive 1999/45/EC and Repealing Council Regulation (EEC) No 793/93 and Commission Regulation (EC) No 1488/94 as well as Council Directive 76/769/EEC and Commission Directives 91/155/EEC, 93/67/EEC, 93/105/EC and 2000/21/EC (OJ L 396, 30.12.2006, p. 1).

[5] Directive 2004/37/EC of the European Parliament and of the Council of 29 April 2004 on the Protection of Workers from the Risks Related to Exposure to Carcinogenic or Mutagens at Work (OJ L 229, 29.6.2004, p. 23).

[6] European Code Against Cancer (2003), available at: http://www.cancercode.org.

[7] Council Recommendation 2003/878/EC of 2 December 2003 on Cancer Screening (OJ L 327, 16.12.2003, p. 34).

[8] Report from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions: Implementation of the Council Recommendation of 2 December 2003 on Cancer Screening (2003/878/EC) - COM(2008) 882.

[9] As set out in the Recommendation, these are the cancers for which the criteria are met that screening should only be offered if the screening is proved to decrease disease-specific mortality, if the benefits and risks are well known, and if the cost-effectiveness of the screening is acceptable.

[10] Directive 2001/20/EC of the European Parliament and of the Council of 4 April 2001 on the Approximation of the Laws, Regulations and Administrative Provisions of the Member States Relating to the Implementation of Good Clinical Practice in the Conduct of Clinical Trials on Medicinal Products for Human Use (OJ L 121, 1.5.2001, p. 34).

[11] Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the Protection of Individuals with Regard to the Processing of Personal Data and on the Free Movement of such Data (OJ L 281, 23.11.1995, p. 31).

[12] Within the frames of the Health Programme, joint action refers to activities carried out by the Community and one or more Member States or by the Community and the competent authorities of other countries participating in the Programme together.