",mm COMMISSION OF THE EUROPEAN COMMUNITIES 
COM(94) 83 final 
Brussels, 29.03.1994 
94/0105 (COD) 
«Klv 
»*<•* '1» - • Proposal for a 
EUROPEAN PARLIAMENT AND COUNCIL DECISION 94/0105 (COD) 
",',- '"if"4|pP adopting an action plan 1995-1999 to combat cancer within 
the framework for action in the field of public health 
(presented by the Commission) 
COMMUNICATION FROM THE COMMISSION 
concerning the fight against cancer in the context of the 
framework for action in the field of public health 
EXPLANATORY MEMORANDUM 
Cancer, which is responsible for one quarter of all deaths in the European Community, has 
always been a central concern of national health authorities. Along with accidents, it ranks 
as the main cause of early death (prior to the age of 75). In recent decades there has been 
a significant increase in mortality due to cancer as the average age of the population has 
increased. The most recent data (1990) show an annual rate of 1 300 000 new cases of 
cancer and 840 000 deaths due to it in the European Community. The incidence of cancer 
is increasing rapidly among those over 50; the median age at which cancer is diagnosed is 
approximately 65 in the Community. It is anticipated that mortality due to cancer will 
increase over the next 15 years in the absence of strategies to combat cancer which include 
effective measures for prevention and treatment. 
The age-related increase in the incidence of cancer is the reason why worthwhile historical 
or geographical comparisons can only be made on age-standardised populations. With such 
populations, two facts emerge: 
the frequency of cancer at a given age has not varied noticeably over recent decades; 
it is higher in the northern Member States, and the Community average is 
approximately 15% lower than in the countries of Central and Eastern Europe. 
Taking four age groups into consideration, the findings are as follows: 
cancer is the second cause of death after accidents among children under 15, even 
though mortality has declined sharply as a result of progress in treatment; 
it is also the second cause of death after violent death (accidents or suicides) for those 
aged 15 to 30; 
it is a significant cause of mortality for those between 30 and 65; 
for those over 65 it is the second cause of mortality, significantly below 
cardiovascular diseases, the incidence of which increases more quickly with age than 
that of cancer in this age group. 
Recent data confirm that a significant proportion of cancers and of deaths through cancer 
may be linked to what may be termed "lifestyles". It has been established that 30% of 
cancers can be attributed to tobacco and that a smaller, though not insignificant, proportion 
of deaths by cancer may be ascribed to excessive alcohol consumption. The importance of 
dietary factors has still to be properly established, although the fact that it is an influence 
has been shown (some experts consider that 30% of deaths are linked to it). It is generally 
accepted that a balanced diet, including an adequate intake of fruit and vegetables is an 
important protection against some of the more frequent cancers. Atmospheric pollution, 
dietary contaminants and ionising radiation are directly responsible for less than 2% of 
cancer-related deaths. It is generally accepted that 70% of cancer-related deaths have their 
origin in individual choices affecting our lifestyles and environment. 
The European Council took note (in May and December 1985) of the concern shown by 
the competent national authorities and by Community citizens in the face of this disease and 
decided to establish a "Europe against Cancer" programme. It was then relayed via the 
European Commission, the Council of Ministers and the European Parliament. An initial 
action plan was successfully implemented in 1987-1989. In the light of the encouraging 
results obtained, the Council and the European Parliament approved the implementation of 
a second action plan for 1990-1994. These action plans have been the subject of annual 
reports by the Commission, forwarded regularly to the Council. In addition, in accordance 
with the Council Decision of 17 May 1990, an evaluation report on the first six years of 
operation of the programme was approved by the Commission on 15 March 1993 and 
forwarded to the Council and the European Parliament for examination. In its resolution of 
13 December 1993, the Council recognised the importance of continuing the "Europe 
against Cancer" programme and asked for a third action plan to be drawn up in due course. 
In its resolution of 27 May 1993, the Council called for the content of this third action plan, 
while ensuring continuity with the preceding plans, to take account of other activities 
undertaken by the Community in the field of public health, particularly those to be 
implemented in the context of the new Article 129 of the Treaty establishing the European 
Community. On 24 November 1993 the Commission adopted a communication on the 
framework for action in the field of public health which, among other things, takes account 
of the wishes of the European Parliament and of the Council in this matter and places the 
fight against cancer among the priorities identified by the Commission and describes its 
relationship to them. 
Another aim of the action plan is to ensure complementarity with various Community 
initiatives, including the protection of workers and consumers. Its main aim is to increase 
knowledge of the causes of cancer and possible methods of prevention. Ensuring wider 
dissemination of knowledge of the causes and prevention of cancer and encouraging 
improved comparability of information on the subject, it will contribute to the achievement 
of Community objectives and stimulate measures at national level in the Member States. 
To this end, there are recommendations for the implementation of 20 measures in the most 
important fields: collection of data, information, health education, cancer training for health 
care workers, early detection and screening, studies and measures relating to the quality of 
care and, finally, research. In accordance with the principle of subsidiarity as set out in the 
Commission communication COM(93) 559 of 24 November 1993, Community action is 
designed in such a way as to assist Member States in the fulfilment of their objectives in 
combating cancer, and it will be implemented in such a way as to maximize the 
Community added value. 
This proposal for a Council Decision takes account of the opinions expressed by the 
European Parliament and by the Member States, particularly in the light of the recent 
evaluation report. It reflects the experience accumulated by the Commission during the first 
two action plans during which it has been ably assisted in its work by the high level 
committee of cancer experts drawn from the Member States. The proposal takes account 
of the principle of subsidiarity, recognizes that situations differ in the Member States and 
introduces the appropriate consultation procedures and suitable assessment measures for the 
activities to be undertaken. 
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 
THE EUROPEAN PARLIAMENT AND THE COUNCIL OF THE EUROPEAN UNION, 
Having regard to the Treaty establishing the European Community, and in particular Article 129 
thereof, 
Having regard to the proposal by the Commission(,), 
Having regard to the opinion of the Economic and Social Committee(2), 
Having regard to the opinion of the Committee of the Regions(3), 
Whereas, at its meetings in June 1985 in Milan and in December 1985 in Luxembourg, the 
European Council underlined the advantages of launching a European programme against cancer; 
Whereas the Council and the representatives of the Governments of the Member States meeting 
within the Council adopted a resolution(4) on 7 July 1986 on a first programme of action of the 
European Communities against cancer and on 17 May 1990 Decision 90/238/Euratom, ECSC, 
EEC(5) establishing a second action plan in the context of the "Europe against Cancer" programme 
for the period 1990-1994; 
Whereas the European Parliament, in its Resolution of 15 December 1993, asked that activities 
against cancer be intensified16*; 
Whereas in its Resolution of 13 December 1993(7), the Council invited the Commission to submit 
in due course a draft third action plan, taking into account the Council Resolution of 
27 May 1993 on future action in the field of public health as well as the objectives and 
improvements set out in the Annex thereto; 
(i) 
(2) 
(3) 
(4) 
(5) 
(6) 
(7) OJNoC 184, 23.7.1986, p. 19. 
OJNoL 137, 30.5.1990, p. 31. 
OJNoC 15, 18.1.1994, p. 1. 
Whereas the prevention of cancer is a priority for Community action within the framework for 
action in the field of public health set out by the Commission while remaining compatible with 
other measures already undertaken by the Community in this field; 
Whereas, in accordance with the principle of subsidiarity, action on matters not under the 
exclusive competence of the Community, such as action on cancer prevention, must be 
undertaken by the Community only when, by reason of their scale or effects, it may be better 
carried out at Community level; 
Whereas cooperation with the competent international organisations and with non-member 
countries should be strengthened; 
Whereas cancer is a major disease associated with lifestyle, and the inherent risk factors need to 
be overcome, especially tobacco consumption, which also has an effect on combating other 
diseases, in particular cardiovascular diseases; 
Whereas, by ensuring wider dissemination of knowledge of the causes of cancer and of its 
prevention, ensuring improved comparability and dissemination of information on these subjects, 
and developing complementary actions especially in health education, the programme will 
contribute to the achievement of the Community objectives set out in Article 129; 
Whereas an important role is played in the implementation of the programme by the Advisory 
Committee and the National Coordinating Committees; 
Whereas, from the operational point of view, the investment made during the preceding action 
plans in terms of both the European pilot networks and of the mobilisation of all those involved 
in combating cancer should be safeguarded and developed; 
Whereas, however, possible duplication of effort should be avoided by the promotion of 
exchanges of experience and by the joint development of basic information modules for the 
public, for health education and for training members of the health professions; 
Whereas, in order to increase the value and impact of the action plan, a continuous assessment 
of the measures undertaken should be carried out, with particular regard to their effectiveness and 
the achievement of objectives both at national and Community level and, where appropriate, to 
make the necessary adjustments; 
Whereas this action plan should be of five-year duration in order to allow sufficient time for 
actions to be implemented to achieve the objectives set, 
HAVE DECIDED AS FOLLOWS: 
Article 1 
A Community plan of action against cancer is adopted for the period 1 January 1995 to 
31 December 1999. 
Article 2 
The Commission shall ensure implementation of the actions set out in the Annex in accordance 
with Article 5 and in close cooperation with the Member States and with institutions and 
organisations active in the prevention of cancer. 
Article 3 
The budgetary authority shall determine the financial resources available for each financial year. 
Article 4 
The Commission shall ensure that there is consistency and complementarity between the 
Community actions to be implemented under this action plan and the other relevant Community 
programmes and initiatives including the Biomedical and Health Research Programme under the 
Community's framework programmes for research. 
Article 5 
In implementing this action plan, the Commission shall be assisted by an advisory committee 
consisting of representatives of each Member State, and chaired by the representative of the 
Commission. 
The representative of the Commission shall submit to the committee a draft of the measures to 
be taken. The committee shall deliver its opinion on the draft, within a time limit which the 
chairman may lay down according to the urgency of the matter, if necessary by taking a vote 
The opinion shall be recorded in the minutes; in addition each Member State shall have the right 
to ask to have its opinion recorded in the minutes. 
The Commission shall take the utmost account of the opinion delivered by the committee. It shall 
inform the committee of the manner in which its opinion has been taken into account. 
Article 6 
1. In the course of implementing this action plan, cooperation with non-r ^mber countries and 
with international organisations competent in the field c/ public health, including the World 
Health Organisation and the International Agency for Research on Cancer, shall be 
encouraged. 
2. The EFT A countries and the countries of Central and Eastern Europe may be associated 
with the activities described in the Annex under the conditions set out in the agreements 
concluded with the Community. 
Article 7 
1. The Commission will publish an annual report on the progress of the action plan and on 
potential Community financing in the various fields of action, taking into account the 
reports to be drawn up by each of the Member States. It shall be forwarded to the European 
Parliament, the Council, the Economic and Social Committee and the Committee of the 
Regions. 
2. On the basis of an interim report to be submitted by the Commission before the end of 
1997, the European Parliament and the Council will evaluate the actions undertaken. An 
overall report will be submitted at the end of the action plan. 
Done at Brussels, For the European Parliament For the Council 
The President The President 
ANNEX 
MEASURES TO BE IMPLEMENTED IN THE PERIOD 1995 TO 1999 
I. CANCER REGISTERS AND EPIDEMIOLOGICAL STUDIES 
1. Support for exchanges of information and experience relating to the collection and 
dissemination of reliable and comparable data for cancer registers (incidence, mortality and 
survival rate). Development and strengthening of a European network in cooperation with 
the International Agency for Research on Cancer (IARC). 
2. Support for the carrying out of epidemiological studies at European level and for the 
dissemination of their conclusions with regard to the identification of carcinogens (physical, 
chemical and biological), the risks arising from exposure to them, methods of prevention 
and for estimating survival rates and sources of disparities in those rates. On the basis of 
these conclusions, support for the drawing up and dissemination of recommendations. 
Cohort studies on cancer, diet and health (EPIC network), support for epidemiological 
studies based on research into nutrition as a potential preventive factor (identification of 
protective agents, modification of specific dietary factors) and, where appropriate, 
preventive chemical agents. 
H. PREVENTION 
A. Public information 
3. Establishment of an annual "Europe against Cancer" week. 
4. Improving the effectiveness of cancer prevention messages, in particular the 
recommendations of the European Code against Cancer, by supporting targeted measures 
(for teachers, general practitioners, etc.) and pilot projects, studies and analyses of health 
promotion techniques and assessments of action in this field. 
5. Supporting pilot action networks for providing information and exchanges with regard to 
cancer prevention, taking into account the recommendations of the European Code against 
cancer and those of the committees of experts meeting for this purpose in order to 
contribute to the highlighting and dissemination of best practice. 
6. Promoting information and awareness-raising campaigns for specific population groups on 
health promotion and cancer prevention, particularly in public places and at work. 
7. Encouraging projects with a European dimension relating to the p « ention of tobacco 
consumption; assessment of the implementation of recommendations on the use of tobacco 
in public places, particularly on public transport and in education establishments. Promotion 
of a policy aimed at protecting the most vulnerable groups from the risk of passive 
smoking, in particular pregnant women and children. Assessment of the effect of measures 
taken in the Member States to reduce tobacco consumption, for example by the banning and 
control of direct or indirect advertising, exclusion of tobacco from the price index and 
dissemination of knowledge acquired from such assessments. Support and assessment of 
pilot measures for preventing tobacco consumption as part of the exchange networks 
between Member States, for example networks of no-smoking towns, no-smoking hospitals 
and youth clubs in cooperation with health-care workers and teachers. 
8. Selection dissemination and evaluation of the impact of the best methods of reducing 
tobacco consumption in the Member States as part of pilot measures to implement these 
methods in liaison with health-care workers. Continuing classification of dangerous 
substances and preparations with the aim of improving packaging and labelling. 
B. Health education 
9. Contributing to the formulation and implementation of integrated health education 
programmes in different contexts, with cancer prevention given a particularly important 
role. Definition and implementation of supplementary cancer prevention projects for specific 
groups in different contexts. Evaluation of health education initiatives with priority being 
given to making individuals more aware of their responsibility for their own health, 
preventing tobacco consumption, promoting a healthy diet and making people aware of the 
risks associated with excessive exposure of the skin to ultraviolet radiation, targeted at 
young people. 
10. Support for exchanges of experience under the integrated health education programmes with 
the aim of improving initial and continuing training for teachers and project supervisors in 
the field of cancer prevention, taking account in this context of the experience gained in the 
framework of programmes such as Erasmus and the supporting actions of the Commission 
in the education field. 
11. Support for the production, dissemination and evaluation of the impact of Community 
teaching materials relating to cancer prevention, particularly those tested in the pilot 
networks. 
12. Implementation of studies and dissemination of their conclusions, making it possible to 
improve the level of knowledge on the perceptions of young people with regard to cancer, 
tobacco, diet and the risks associated with excessive exposure of the skin to ultraviolet 
radiation. Carry out analyses with the aim of increasing the effectiveness of preventive 
programmes among children and young people. 
10 
C. Training for health-care workers 
13. Pursuing the implementation of the Commission recommendation of 8 November 1989 
concerning the training of health personnel in the matter of cancer; assistance with the 
introduction and periodic assessment of the impact of the European pilot networks on initial 
and continuing training in cancer for the medical, nursing and dentistry professions. 
14. Support the mobility of the health professions (particularly trainers) in order to improve 
theoretical and practical knowledge of cancer (primary prevention, mass screening, 
particularly for cervical and breast cancer, early diagnosis and quality of care) between 
those centres of excellence in Member States offering training of a high quality, where such 
mobility is not ensured under existing Community programmes such as COMETT II or 
FORCE. 
15. Support exchanges of experience and the drawing up and dissemination of conference 
recommendations for a consensus on good medical practice and of recommendations by 
groups of experts in order to speed up the dissemination and implementation of the results 
of controlled studies. Preparation of teaching materials of European interest aimed at 
improving training in cancer for health-care workers, particularly through the use of 
interactive computer programmes; assessment of the impact of these materials in the pilot 
networks. In particular, support for the development, implementation and evaluation of 
prevention modules intended for the health professions and of models to assist in diagnosis 
and in making decisions with regard to treatment. 
IH. PREVENTION BY MEANS OF EARLY DETECTION AND SYSTEMATIC 
SCREENING 
16. Support the introduction and evaluation of European pilot project networks in the field of 
mass screening for breast and cervical cancer, on the basis of recommendations established 
at European level with regard to ensuring the quality of screening, and support for the 
organisation of meetings to examine the feasibility of extending pilot projects to national 
and regional levels. 
17. Support the preparation at European level and dissemination of a common terminology and 
classification in order to improve the quality of anatomical and cytopathological 
interpretation, particularly of suspect growths in the breast and uterus, in particular for 
anatomists and cytopathologists in the European Community. 
18. Support European feasibility studies for early mass screening for other cancers (of the 
ovary, prostate, skin, colon/rectum and mouth), taking particular account of the medical, 
psychological, social and economic aspects. 
IV. STUDIES AND MEASURES RELATING TO THE QUALITY OF CARE FOR 
CANCER PATIENTS 
19. Support European studies and dissemination of their conclusions, particularly in the context 
11 
of European-level meetings and exchanges of experience, in order to gain a better 
understanding and improve the effectiveness of quality control methods both in diagnosis 
(radiological and anatomo-cytopathological examination) and in treatment (radiation therapy 
and chemotherapy), including palliative care, taking into account the psychological and 
social aspects, with particular regard to the quality of life of patients. Dissemination and 
evaluation of best practice in quality assurance in the pilot project networks. 
V. RESEARCH 
20. Make a supporting contribution to selecting priorities for cancer research to be carried out 
under the Community's framework programmes for research and specifically the Biomedical 
and Health Research Programme which includes basic and clinical cancer research. Support 
for the establishment of an inventory of European basic and clinical cancer research 
measures; help with the transfer to clinical trials of the results of basic research; 
information exchange networks for clinical trials in progress, and help with the launching 
of multiple-centre and multinational clinical trials in order to speed up the assessment of 
new methods of care. 
12 
COMMUNICATION OF THE COMMISSION 
CONCERNING THE FIGHT AGAINST CANCER IN THE CONTEXT OF THE 
FRAMEWORK FOR ACTION IN THE FIELD OF PUBLIC HEALTH 
13 
TABLE OF CONTENTS 
I. INTRODUCTION 15 
II CANCER TRENDS IN THE MEMBER STATES OF THE EUROPEAN 
UNION 16 
III. OVERVIEW OF ACTIONS ON CANCER ALREADY TAKEN 
AT COMMUNITY LEVEL 20 
IV THE EUROPEAN COMMUNITY APPROACH 24 
a. Objectives and means 24 
b. The Public Health Framework and the "Europe against Cancer" 
programme 25 
c. Cooperation between Member States 27 
d. Cooperation with international organisations and third countries 28 
V. THE THIRD ACTION PLAN 29 
a. Priority actions 29 
a.l. Cancer registries and epidemiological studies 30 
a.2. Specific preventive actions 31 
a.2.1. Information of the public and specific groups 32 
a.2.2. Health education 33 
a.2.3. Training of health personnel 34 
a.3. Early detection and systematic screening 35 
a.4. Quality control in care (including palliative care) 37 
a.5. Contribution to formulation and dissemination of research .... 38 
b. Consultation and participation mechanisms 39 
b.l. Advisory Committee 39 
b.2. Expert Group of high level cancer experts 39 
b.3. Other groups involved 39 
c. Evaluation and reports 40 
c.l. Annual report on the execution of the action plan 40 
c.2. Independent peer review evaluation of the major 
actions and studies supported 40 
c.3. Interim and global reports on the effectiveness 
of the Action Plan 40 
d. General information activities 40 
VI. RESOURCES 41 
14 
I. INTRODUCTION 
1. In its communication of 24 November 1993 on the framework for action in the field of 
public health (COM (93) 559 final) the Commission defined a framework for future 
action at Community level in order to attain the objectives on health protection laid 
down in Articles 3 (o) and 129 of the Treaty establishing the European Community. The 
role of the Community is identified as underpinning the efforts of the Member States 
in the public health field, assisting in the formulation and implementation of objectives 
and strategies, and contributing to the provision of health protection across the 
Community, setting as a target the best results already obtained in a given area 
anywhere in the Community. 
2. In initiating action under Article 129, the Community has to address itself to preventing 
disease and protecting health. Based on the criteria laid down in the Commission 
communication cancer has been identified as a priority for Community action. Cancer 
is a disease which: 
- causes, in the absence of intervention, significant premature death and/or overall 
high death rates; 
- causes significant ill health including high morbidity and/or disability; 
- has significant implications for the quality of life as well as major socio-economic 
effects 
Objective data (mortality and morbidity figures and health indicators) and more 
subjective perceptions confirm that cancer is indeed a major health scourge. Moreover, 
cancer is a disease for which, because of its lifestyle related risk factors, practicable 
measures for prevention exist: this underlines the importance of continuing with 
preventive campaigns. 
3. In recent decades the health situation in Member States has been marked by the 
emergence of two types of diseases linked to lifestyle and ageing, namely cancers and 
cardiovascular diseases. These are by far the leading causes of death among over 40s 
in the Union and were thus already being taken very seriously by national health 
authorities before becoming in 1985, in the case of cancer, the focus of preventive 
action by the Community. 
4. Cancers are responsible for about a quarter of all deaths in the European Union, 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 Union have gone up sharply because of the progressive ageing of the 
population, cancer incidence rising rapidly with age from 50 upwards and the median 
age of initial diagnosis of cancer being approximately 65 years. Current cancer 
registration data show that this trend of increasing incidence and mortality will continue 
in the next 15 years, and could even accelerate in the absence of adequate preventive 
strategies. 
15 
IL CANCER TRENDS IN THE MEMBER STATES OF THE EUROPEAN UNION 
5. The most recent data (1990) indicate an annual incidence of 1.3 million new cases of 
cancer and of 840 000 deaths from cancer each year in the European Union. Thanks to 
the existence of a good network of cancer registers, which now covers the majority of 
Member States of the European Union, it is possible to compare the epidemiological 
situation in most of the Member States. 
6. The mortality incidence* rates were always higher for men than for women in all 
Member States, the difference being particularly marked in certain countries. In the 
Union as a whole, women are 40% less likely to die from cancer than men. The higher 
incidence of morbidity and mortality in men is mainly attributable to heavier 
consumption of tobacco and alcohol by men, followed by occupational exposure to 
carcinogens and biological differences between the two sexes. The leading cause of 
cancer mortality in men is lung cancer (130 000 cases per year), followed by cancer of 
the prostate, of the colon and of the stomach. In women the leading cause of mortality 
is breast cancer with more than 150 000 cases per year, followed by lung cancer, cancer 
of the colon, of the stomach, and of the genital organs. However, in certain countries 
(Denmark, the United Kingdom) where tobacco consumption among women has been 
high for a long time lung cancer can be as frequent as breast cancer. There are 7 500 
new cases of cancer detected each year in children, and 2 500 deaths. The predominant 
forms of childhood cancer are leukaemia and cancers of the nervous system (the brain) 
and the lymphoma. 
7. Because the incidence of cancer increases with age, useful comparisons at the historical 
or geographical level can only be made in populations standardised for age. Two facts 
can be observed in such populations: 
- at constant age, cancer frequency has not varied significantly in recent decades; 
- cancer morbidity and mortality of men is approximately 10% higher in the Union 
than in the Scandinavian countries and approximately 15% lower than in the 
countries of Central and Eastern Europe. The gap is bigger still with the countries 
of the former USSR, where cancer incidence has risen considerably in recent 
decades. 
8. For a closer analysis it is necessary to do what is common practice in epidemiology and 
consider four age groups. In children (i.e. the under-15s) cancer is the second most 
frequent cause of death, after accidents. Nevertheless, in this age group cancer mortality 
has been reduced considerably thanks to advances in cancer therapy. In the 15-30 age-
group cancer is again the second most frequent cause of death, after violent death 
(accidents or suicides). Here too, mortality has declined considerably, although 
morbidity has remained constant. In the 30-65 age-group cancer remains a significant 
cause of mortality, especially lung cancer in men, although it is somewhat 
overshadowed by death from cardiovascular disease. For woman however, breast cancer 
is, in this age category, the leading cause of death. Over 65 years of age cancer is the 
second cause of mortality after cardiovascular disease. 
16 
9. If we subdivide cancers into two groups - cancers due to tobacco or tobacco and alcohol 
(cancer of the lungs, oesophagus, upper airways/digestive tract and the bladder), and 
other cancers - we see that the incidence of morbidity for the first group has increased 
in recent decades, as has mortality, since there has been very little progress in the 
treatment of these cancers with a poor prognosis. The preponderant role of tobacco is 
accentuated even further if one considers the number of years of life lost due to 
tobacco-related cancers, for these cancers occur at earlier ages than other cancers. As 
regards the other cancers, there has been a slight reduction in the incidence of both 
morbidity and mortality in this age group, and some progress in treatment has been 
observed. 
10. The available data according to which 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, 
demonstrate that over two thirds of deaths from cancer are linked to lifestyles and 
therefore, in principle, can be avoided by changing behaviour. The direct roles of air 
pollution and food contaminants appear to be extremely low (less than 2%), as 
witnessed by the stable incidence of lung cancers in non-smokers and the considerable 
decline in the frequency of stomach cancers. However, given the long delays between 
exposure to risk factors and the appearance of most cancers the mortality and morbidity 
rates reflect the risks encountered in earlier years. In other words an exposure to cancer-
inducing factors today might cause a cancer which would not become apparent for a 
number of years. 
11. There are considerable differences between Member States as regards the incidence of 
certain types of cancers. For example, cancer in the buccal cavity linked to the 
combination of tobacco and alcohol in men varies from 1% in the Netherlands to 9% 
in France. In women, the rates are about five times lower than those observed in men. 
An upward trend in oral cancer in young people has been observed in several Members 
States. 
12. The Union countries with the highest incidence of tobacco-related cancers are the north­
western countries (Belgium, Denmark, the Netherlands and the United Kingdom). In 
these countries, tobacco consumption has fallen slightly among men but has risen 
significantly among women. In the United Kingdom, for example, lung cancer has 
become the most frequent cause of cancer death among women in certain regions and 
age groups. As regards the social environment of smoking, the same pattern applies in 
all Member States: the lower the level of education and the lower the socio-economic 
status, the higher the consumption of tobacco. In the United Kingdom, for example, 
tobacco information campaigns have had a considerable effect on the more socially 
advantaged classes. Smoking, and the cancers associated with it, are becoming a 
handicap specific to the more disadvantaged social classes. France has the highest 
mortality incidence due to tobacco and alcohol-related cancers. Again the socio­
economic status is a significant factor. For example, cancer of the oesophagus is six 
times more frequent among the more disadvantaged social groups than among the well-
educated. 
17 
13. As regards the cancer incidence and mortality with respect to specific tissues and 
organs, the following trends are observed: 
14. Lung: Cancer of the lung is the most common cancer in the Union, representing almost 
30% of all cancer deaths in men and 10% in women. Tobacco smoking, by far the most 
important cause of lung cancers, explains the dramatic increase in its frequency over the 
past 50 years. At present incidence rates appear to have stabilized at a high level in a 
number of Member States and are slightly decreasing in the United Kingdom. In 
contrast in women, rapid increases in incidence and mortality rates are occurring in the 
Member States in the South of Europe. 
15. Colon and Rectum: Cancers of the colon and rectum taken together are, after lung 
cancer, the most commonly occurring cancers in the Union. Incidence and mortality are 
high in the northern and western parts of the E. These cancers are associated with the 
modern Western diet which is high in fat and protein, factors that may increase the risk, 
and low in vegetables and fruit and fibre which are thought to be protective. Certain 
occupational exposures, some aspects of reproductive history, reduced physical activity, 
and a history of cholecystectomy, although their likely impact is thought to be quite 
small, have all been suggested as a potential cause of some of these cancers. Incidence 
rates have been stable or increasing in all Member States. In contrast, mortality rates 
have decreased, most steeply in women. 
16. Breast: Breast cancer is the most common cancer of females in the Union and 
represents 24% of all cancer cases and 19% of cancer deaths. Incidence and mortality 
are higher in northern Member States (Denmark, the Netherlands, U.K.) than in the 
Mediterranean countries (Greece, Spain, France and Italy), and the geographical 
variation is somewhat less than two-fold. Incidence rates have increased in all Member 
States while mortality has started to decrease recently in younger women in some 
Northern Member States. The following risk factors are associated with an increased risk 
of breast cancer: having a family history of the disease, increased body size, a past 
history of benign breast disease, reproductive factors including late age at first birth, 
nulliparity, early menarche and late age at menopause, the use of oral contraceptives at 
young ages and unopposed oestrogens for the relief of menopausal symptoms, and 
exposure to ionizing radiation. Diet, especially one rich in fat and protein of animal 
origin, has been suggested as having a causal role; diet during childhood may be 
especially important. Several studies have suggested a positive association between 
increased alcohol consumption and this cancer. 
17. Stomach: The incidence of stomach cancer has been decreasing in nearly all countries 
of the world over the past decades, but this fatal disease is still among the most 
common malignancies. In the Union, stomach cancer comprises 6% of all cancer deaths. 
This cancer is particularly frequent in Portugal, in Central Italy and Southern Germany. 
In all Member States, the rate is twice as high in men as in women. The decreasing 
dependence on starchy smoked, salted and fried foods and an increasing consumption 
of vegetables and citrus fruits could be responsible for the decline. The European 
prospective epidemiological survey on the links between diet and cancer, undertaken by 
the "Europe against Cancer" programme will no doubt throw more light on this. 
18 
18. Buccal cavity, pharynx and oesophagus: The proportion of deaths attributable to 
cancer of the buccal cavity and pharynx varies greatly between European countries, and 
ranges in men from 1% to 9% depending on the Member State. The rate in women is 
around 20% of the rate in men, when considered over all Member States. Excessive 
consumption of alcohol, particularly if linked with smoking, and tobacco consumption 
are risk factors for cancer of the buccal cavity and pharynx. The European pattern of 
oesophageal cancer in men resembles that of cancer of the buccal cavity and pharynx 
and indeed, the dominating risk factors, alcohol and tobacco, for these two groups of 
diseases are identical; in women the pattern resembles that of lung cancer. 
19. Prostate gland: Prostate cancer accounts for an estimated 12% of all new male cancer 
cases each year in the Union and 10% of all cancer deaths. It is the second most 
frequent cancer of men. Incidence and mortality are higher in the northern countries 
than in the south but within these broad geographic divisions the variation is slight. The 
aetiology of prostate cancer remains obscure although sexual factors have been 
suggested as important and dietary factors may also be associated with increased risk, 
especially high fat and protein consumption. Rates of this cancer have been increasing 
in all Member States although these rates may reflect the introduction of diagnostic 
practices which have increased the availability of tissue specimens for examination. 
20. Cervix Uteri: The factor implicated in cancer of the cervix is infection of the cervix 
with human papilloma virus (HPV) particularly types 16 and 18. This infection is 
acquired most commonly by sexual intercourse, thus explaining the association which 
has been observed with numbers of sexual partners and age at first intercourse. 
Incidence and mortality have generally decreased partly attributable to the success of 
screening. 
21. Skin: Basal cell and squamous cell cancers of the skin are relatively frequent 
particularly in individuals with lightly pigmented skin. Risk factors are excessive 
exposure to ultraviolet radiation, for example sunlight, or occupational exposure to 
carcinogenic agents. Fortunately, these cancers are relatively easy to detect and have 
a high cure rate. Mortality rates are therefore considerably less than incidence rates. 
Incidence of melanoma varies four-fold in males in the Member States, and five-fold 
in females, with the lowest incidence in Southern Member States and a higher incidence 
in more northern countries. While mortality tends to be much lower than incidence, a 
similar strong north-south gradient is seen in both incidence and mortality and in both 
sexes. Unlike other cancers, there is a female excess in incidence in all countries. While 
there is evidence that sun exposure increases the risk of malignant melanoma, the 
relationship is not straightforward. The inconsistency is thought to be due to differing 
patterns of sun exposure and a gradient of risk for melanoma which declines from the 
north to the south of Europe and matches the increasing protective natural pigmentation 
of the skin. Incidence rates of melanoma have increased steeply by about 7% annually 
in most Member States. 
19 
III. OVERVIEW OF ACTIONS ON CANCER ALREADY TAKEN AT 
COMMUNITY LEVEL 
22. In May 1985, the Heads of State and Government, meeting in the European Council in 
Milan, called for a coordinated European action against cancer. In response, the 
Commission prepared a proposal for a "Europe against Cancer" programme which was 
adopted in 1987. Since then, the European Council has played an important role on 
several occasions in the context of the "Europe against Cancer" programme: in 
December 1986 in London, by deciding that 1989 would be the European Year of 
Information on Cancer; and in December 1989 in Strasbourg, by renewing its support 
for the programme and for the second action plan 1990-1994. 
23. The Council has demonstrated a particular interest in the subject on numerous occasions 
since 1985 and has adopted Resolutions and Decisions concerning the implementation 
of the first two action plans and of certain elements of its strategy, notably in the fight 
against smoking. The Council Resolution of 13 December 1993 invited the Commission 
to submit in due course a draft third action plan, taking into account the Council 
resolution of 27 May 1993 on future action in the field of public health as well as the 
objectives and improvements set out in the Annex of this resolution. 
24. The European Parliament has also regularly called upon the Commission to act on 
cancer, in particular as regards smoking, quality control in delivery of care, palliative 
care and campaigns to inform the public. In its Resolution of 15 December 1993 the 
Parliament called for the Union activities in the campaign against cancer to be 
intensified. 
25. The Economic and Social Committee has allied itself to this strategy and has issued 
favourable opinions on the conduct of the "Europe against Cancer" programme. 
26. The Commission has translated these concerns into action through two action plans 
against cancer. A first action plan 1987 - 1989 was implemented with success. A second 
action plan 1990 - 1994 was then adopted in May 1990, with a larger budget. This 
action plan is due to finish at the end of 1994. In continuing the campaign beyond then 
it will be necessary to pursue those projects which have proved the most valuable. With 
the implementation of the Treaty on European Union the legal basis underpinning this 
Community action has changed: the Programme now comes within the context of 
Article 129 concerning public health. 
27. The first two action plans covered four main areas: 
(a) cancer prevention, with the priority on smoking, since a third of all cancer deaths 
are smoking-related. The measures adopted have included the implementation of 
Community legislation and the Community financing of European studies and 
research, public information campaigns, health education campaigns in schools and 
training of health professionals. The prevention message was publicised in the 
European Code against Cancer, which was drawn up by the Committee of Cancer 
Experts and approved by the Health Ministers in 1987. 
20 
(b) Systematic cancer screening and early detection. Community funding has been 
granted for information, education and training campaigns, for studies and research 
of European interest, and for the establishment of European networks of pilot 
cancer screening projects establishing guidelines for best practice agreed by high 
level experts at European level. 
(c) Concerning training, Community subsidies have supported actions for health 
personnel and exchanges of experience leading to a consensus on good practice 
transferable between Member States. 
(d) Research into cancer. A global strategy was defined by the Committee of Cancer 
Experts during the first two action plans. This concerns basic research, clinical 
research and assistance to mobility of researchers between Member States to 
improve their training. Where applications of a sufficiently high quality were 
received under the Medical and Health Research Programme (1987-1991) and/or 
the Biomedical and Health Research Programme (1990-1994) within the 
Community framework programmes for research, this strategy was reflected in the 
selections made from the open calls under those two programmes. 
21 
28. Community action has taken two forms: on the one hand the use of legal measures such 
as the development of legislation at European level directed towards primary 
prevention0* (campaign against tobacco, exposure to carcinogenic agents at the 
workplace, etc.); on the other hand Community finance has been used to support 
initiatives which respond to the priorities of the first two action plans. 
d) Resolution of the Council and of the representatives of the Governments of the 
Member States meeting within the Council, of 7.7.1986 on a programme of action 
by the European Communities against cancer (OJ No C 184, 23.7.1986, p. 19). 
Resolution of the Council and of the representatives of Member States meeting 
within the Council, of 18.7 1989 on the banning of smoking in places open to ilio 
public (OJ No C 189, 26.7.1989, p. I). 
Council Directive 89/622/EEC of 13.11.1989 on the approximation of the laws, 
regulations and administrative provisions of the Member States concerning the 
labelling of tobacco products (OJ No L 359, 8.12.1989, p. 1), modified by the 
Directive 92/41/EEC which, in its Alicle 8(a) prohibits the placing on the market 
of tobacco for oral use. 
Decision 90/238/Euratom, ECSC, EEC of the Council and the representatives of 
the Governments of the Member States meeting within the Council, of 17.5.1990 
adopting a 1990 to 1994 action plan in the context of the "Europe against Cancer" 
programme (OJ No L 137, 30.5.1990, p. 31). 
Council Directive 90/239/EEC of 17.5.1990 on the approximation of the laws, 
regulations and administrative provisions of the Member States concerning the 
maximum tar yield of cigarettes (OJ No L 137, 30.5.1990, p. 36). 
22 
29. Finally, the added value from Community action has been demonstrated in the two first 
action plans of the Programme through the identification of common objectives and 
goals, the establishment of effective cooperation between Member States and the 
dissemination and adoption of the most successful practices throughout the Community. 
Examples of this added value are: 
coordination and spread of the European Code against cancer, notably during the 
European Year on Information on Cancer in 1989 and the yearly cancer weeks 
which increased the awareness and the knowledge of general public on cancer in 
particular on prevention and protection measures, and is also brought about a 
willingness to seek prompt treatment; 
support to demonstration programmes in cancer screening and research on 
nutrition and carcinogenic substances which generated results for the benefit of all 
Member States thus increasing the effectiveness of the research investment; 
facilitation of training and professional exchange programmes leading to 
improving standards within the Member States and of dissemination of technical 
standards regarding cancer prevention, cancer diagnosis and quality of care. 
23 
IV. THE EUROPEAN COMMUNITY APPROACH 
a. Objectives and means 
30. The Commission's Communication on the framework for action in the field of public 
health (COM(93) 559 final) proposes, in paragraph 50, four objectives which should 
form the basis of Community action: 
(i) to prevent premature death which particularly affects the young and working 
population; 
(ii) to increase life expectancy without disability or sickness; 
(iii) to promote the quality of life by improving general health status and the 
avoidance of chronic and disabling conditions; 
(iv) to promote general well being of the population particularly by minimising 
the economic and social consequences of ill health. 
The "Europe against Cancer" programme has to address all of these objectives. 
31. From a public health prospective the criteria listed in paragraph 54 of the Commission's 
Communication can also be considered as satisfied since cancer undoubtedly causes 
significant premature death, has a high morbidity, has a major socio-economic impact 
for example in treatment costs, and moreover practicable measures of prevention exist. 
The lessons of the first and second action plans, as established in the evaluation process, 
show that there is substantial scope for added value from Community actions, both from 
economies of scale and from dissemination of the results of projects. 
32. As indicated in the Commission's Communication, Community action will, in particular, 
focus on encouraging cooperation between Member States, lending support to their 
action, promoting in close contact with the Member States co-ordination of their policies 
and programmes. In practice, this will involve the development and implementation of 
networks, joint actions and information exchange systems. In the cancer field many of 
these already exist because of the work which has already been done under the first and 
second "Europe against Cancer" programmes. 
33. Future Community action in the public health field must take account of the principle 
of subsidiarity and the considerations set out in paragraph 27 of the Commission's 
Communication. The Community shall take action only if, and in so far as, the 
objectives cannot be sufficiently achieved by the Member States themselves and can, 
therefore, by reason of the scale or effects of the proposed action, be better achieved by 
the Community. Activities should be selected on the basis of prior appraisal and should 
yield a Community added value while achieving maximum cost efficiency. 
34. The following criteria in particular will be used in future in assessing the need for 
Community action in the cancer field: 
activities on a scale which Member States themselves could not, or could only 
with difficulty, implement; 
24 
activities, the joint implementation of which would offer obvious benefits even 
after taking account of the extra costs involved; 
activity which, because of the complementary nature of work being done at 
national level, enables significant results to be obtained in the Community as a 
whole; 
activity which leads, where the need is recognised, to the establishment of best 
practice norms and standards; 
activities which contribute to the strengthening of solidarity and social cohesion 
in the Community, and promote its overall harmonious development. 
b. The Public Health Framework and the "Europe against Cancer" programme 
35. The third plan of action on cancer is the first programme to be promulgated under the 
public health framework. It is designed to achieve a much-needed continuation of the 
action under the "Europe against Cancer" programme and build on the achievement of 
the two previous action plans. It contains specific activities focused on fighting cancer 
and seeks to increase the capacity of health personnel and professionals and the 
authorities to tackle the scourge of cancer. These activities would be coherent with and 
complementary to other proposed activities under the public health framework organised 
in "horizontal" type programmes. The latter, dealing with underlying causes common 
to many diseases, aim to promote healthy lifestyles and environments using appropriate 
settings and learning opportunities in which reference to specific diseases takes place 
in a structured and appropriate manner. These considerations are particularly relevant 
to information on health intended for the public or specific groups, health education and 
training of health personnel and professionals. 
36. The role of the "Europe against Cancer" programme in health education in schools is 
limited and specific . Limited, because cancer prevention is only one of the objectives 
of health education which must also include prevention of drug misuse, AIDS, suicidal 
tendencies and above all the promotion of health. Nonetheless the specific role of 
cancer is crucial because it creates a substantial motivation among teachers and parents 
and its effects are all too visible in the European population where one in four adults 
dies from cancer. 
37. The Commission will endeavour to ensure that cancer projects enjoy maximum priority 
and adequate funding. They will be given precise objectives directed towards the 
reduction in mortality from cancer from now to the year 2000, which was the initial 
objective and the raison d'être of the Programme. It will give priority to large-scale, 
large-impact projects involving, as far as possible, the participation of governmental and 
non-governmental organisations. The Commission will also contribute, if so requested, 
to the establishment of cooperation arrangements between Member States and will enlist 
the help, where necessary, of competent international organisations. 
25 
38. Many areas of Community policy impinge on the fight against cancer and the 
Commission has undertaken in its Communication on public health to ensure that full 
account is taken of health protection, including therefore cancer prevention, issues that 
arise in any of them. The Commission has established appropriate internal procedures 
to ensure that this commitment is respected through adequate coordination and 
consultation in the development of relevant policies. In addition, the Commission will 
submit, on a yearly basis, a report on the health protection aspects of policies which will 
form part of the Annual Report of the Commission. 
39. Of particular importance in the fight against cancer is research. Article 130 of the 
Treaty concentrates all research from 1994 onwards within the Framework Programme 
system, initially the fourth Framework Programme (1994-1998). Within that there will 
be a second Biomedical and Health Research Programme (1994-1995), which will 
provide for cancer research among other topics. 
40. The strategy concerning prevention of tobacco consumption, which also involves the use 
of other Community policies, will be pursued and developed. Thus, the reform of the 
organisation of the common market for tobacco became effective with the 1993-1994 
marketing year. In the context of the new market arrangements, tobacco production in 
the Community will be cut from 430,000 to 350,000 tonnes, and the expenditure on 
market support from ECU 1,300 million to ECU 817 million. From now on tobacco 
production is subject to strict quotas and no support will be available outside them. The 
reform has also established a special fund which will support studies into the possibility 
of growing less toxic varieties of tobacco. This fund, financed by a levy on the subsidies 
to producers, will also contribute significant sums to information and health education 
linked to the risks of tobacco consumption. As regards taxation related to manufactured 
tobacco products, the Commission will prepare a report which takes account of problems 
that might have arisen in the sector and will, if necessary, draw up a proposal for a 
directive on this matter, with a view to reinforcing the conditions of the establishment 
of the Internal Market, taking into account other objectives of the Treaty (public health, 
agriculture, environment). 
41. Since the adoption of the first pharmaceutical Directive in 1965(2), the pharmaceutical 
legislation of the European Community has constantly pursued two objectives: the 
protection of public health and the free movement of products. The Committee for 
Proprietary Medicinal Products (CPMP), within which the competent authorities of the 
Member States are represented, has considered as a priority the question of development 
of medicinal products for the treatment of cancer. To this end, a guideline on the 
conduct of clinical trials for anticancer medicinal products has been agreed and 
published in the "Rules governing Medicinal Products in the European Community, 
Volume III, addendum July 1990". 
(2) Directive 65/65/EEC: OJ No 22, 9.2.1965. 
26 
42. In order to give patients throughout the Community rapid and simultaneous access to 
important new medicinal products (high technology and biotechnology medicinal 
products), a Community coordination procedure was introduced by 
Directive 87/22/EEC(3). This procedure has been used for a number of medicinal 
products for in vivo diagnosis of cancer, for the treatment of various forms of cancer 
and for the alleviation of side-effects of anti cancer treatments. 
43. June and July 1993, the Council adopted the Regulation and Directives introducing the 
future system for free circulation of medicinal products, comprising a centralized EC 
authorization procedure with binding EC decisions for some categories of medicinal 
products, as well as the establishment of the European Medicines Agency. Under this 
system, new products for cancer treatment will have access to the "centralized 
procedure" by virtue of their clinical importance. This procedure provides for a 
Community evaluation of a product, under the leadership of a rapporteur. The strict 
deadlines laid down for centralized procedures greatly enhance the speedy processing 
of applications, and the resulting binding EC authorization will make these important 
innovative products simultaneously available to patients throughout the European 
Community. The international harmonization of technical requirements within the 
context of the International Conference on Harmonization (ICH) will lead to the 
elimination of duplicative tests and trials, costly both in time and human and financial 
resources, and thus contribute to the rapid access of patients to new medicinal products, 
including those for the treatment of cancer. 
c. Cooperation between Member States 
44. y of the priority actions in the third action plan to combat cancer would significantly 
benefit from a high performance information communication infrastructure to maximise 
the effect of the actions. Whenever relevant, close collaboration with the programme 
Telematics for Areas of General Interest under the Fourth Framework Programme will 
be established in order to stimulate the use and development of such an infrastructure 
as has also been foreseen in the Commission's White Paper on Growth, Competitiveness 
and Employment (Document COM(93) 700 final, Brussels 5 December 1993). 
45. Commission is prepared to assist the Member States in accordance with the 
Commission's Communication on the framework for action in the field of public health 
(COM (93) 559 final).The Commission is specifically requested by the Council, in its 
Resolution of 13 December 1993, concerning future guidelines for the "Europe against 
Cancer" programme, to promote cooperation between Member States in the fields of 
quality control regarding care, palliative care and responsibility for patient welfare. 
Specific proposals are developed below in the section on quality in care. 
(3) OJNo L 15, 17.1.1987. 
27 
d. Cooperation with international organisations and third countries 
46. The process of collaboration with international organisations has developed positively. 
This has been the case with WHO, and in particular with the International Agency for 
Research on Cancer (IARC), in the form of joint projects and coordination work led by 
the latter in the context of the first two action plans. 
47. In the general context of strengthening links between the Community and WHO, 
particular attention will be given to specific preventive actions. Similarly, the already 
close collaboration with the IARC will be pursued in relation to cancer registers 
(especially in the context of the European Network of Cancer Registers), epidemiology 
(through coordination of European studies), indicators, and evaluation of the 
carcinogenicity of chemical substances. In addition, cancer prevention will be 
considered in the context of health education activities carried out by the "European 
Network of health promoting schools" jointly supported by WHO, the Council of Europe 
and the European Community. 
48. Cooperation will be continued with the OECD on the prevention of chemical risks, 
especially carcinogenic risks, due to the environment. The same applies to cooperation 
with the ILO concerning these same risks at the workplace. 
49. Cooperation must be pursued and developed with other international organisations 
dealing with different aspects of cancer prevention. The priorities in such cooperation 
must be the stimulation of exchanges of experience and expertise, the effective 
coordination of existing or planned networks, and the avoidance of duplication of effort. 
50. Forms of collaboration must also be improved with international scientific NGOs, such 
as the FECS (Federation of European Cancer Societies) and the EORTC (European 
Organisation on the Research and Treatment of Cancer), the OECI (Organisation of 
European Cancer Institutes) in training and in developing links with central and eastern 
Europe, the UICC (International Union Against Cancer) and the ECL (European Cancer 
Leagues) for information of the public: all of these possess scientific expertise in their 
respective fields which the Cancer Programme should exploit in its third action plan. In 
particular, there are possibilities for improving collaboration with the UICC for common 
actions in prevention and screening. 
51. In the two preceding action plans fruitful cooperation was established with various 
European third countries, especially Sweden, Norway and Switzerland, which 
participated as formal or informal observers in the Programme, whether in the context 
of scientific projects and in the context of initiatives by anti-cancer leagues and 
associations. This openness will be maintained in the third action plan. In the third 
action plan there will be further collaboration with third countries, and in particular the 
EFTA countries and those countries of Central and Eastern Europe which have signed 
association agreements with the Union. The possible forms of collaboration, including 
the gradual opening up of the Programme to these countries, will be explored. This 
collaboration could cover the collection of epidemiological data, the implementation of 
specific preventive actions and information and education campaigns, the training of 
health personnel, screening and surveillance. 
28 
V. THE THIRD ACTION PLAN 
a. Priority actions 
52. Better monitoring and control of cancer trends depends on improving the collection and 
updating of cancer mortality and morbidity data. Support should therefore be continued 
for those structures which have demonstrated their effectiveness, such as the European 
network of cancer registers, since these open up new perspectives in the field of cancer 
epidemiology. 
53. Since three-quarters of cancer cases are linked to lifestyle, prevention remains a key 
strategy with enormous potential. The campaign against tobacco should be a major 
priority in this field, since tobacco alone is responsible for a third of cancer mortality. 
Moreover, the risks linked to tobacco are well established not only for the direct 
consumers themselves but for those around them (passive smoking). It is therefore 
appropriate to continue the actions to reduce the trend in tobacco smoking especially 
among young people and women. Progress can still be achieved thanks to legislative 
action at Community level as well as by supporting pilot and demonstration projects by 
influential groups such as health professionals, teachers and the media. Other risk 
factors, such as an unbalanced diet, exposure to carcinogenic agents such as ultraviolet 
radiation or dangerous substances present, for example, at the workplace, justify 
continued Community action, both by legislation and by pilot projects for specific target 
groups, taking due account of subsidiarity. In this context public information and school 
health education campaigns are essential for making people more aware of the dangers 
of smoking, excessive drinking, unbalanced diets and the exposure to cancer inducing 
substances. Other population groups need to be targeted, notably children, young people 
and workers. 
54. High quality screening and early detection measures, in particular breast and cervical 
cancer screening, conducted with proper quality assurance mechanisms, would bring the 
number of cancer deaths down, and these, too, are important aspects of the prevention 
strategy. This approach might usefully be extended to cover other cancer sites such as 
the colon, the ovaries, the prostate and the buccal cavity. 
55. At the same time, the action plan should continue to cover other important fields of 
action. Research, for example, needs to be continued, and the Programme will contribute 
to the establishment of priorities, by developing an inventory of research activities 
particularly clinical research. The rapid dissemination of the results of basic research 
and clinical trials will be a priority since this is a field where close cooperation and 
rapid exchanges of information between European cancer research institutes and 
hospitals considerably improve the effectiveness of each national programme. 
56. It is important to continue and develop the initiatives taken at European level on training 
of health personnel, since these have had a positive impact on the quality of training at 
national, regional and local levels and will help to close the gaps which still exist 
between Member States. It is also useful to encourage new initiatives allowing training 
programmes for health personnel to include the most significant recent advances in 
29 
prevention, diagnosis and treatment of cancer. Continuous and in-service training will 
be the key to this action. 
57. In the field of care management the approach adopted in the second action plan should 
be developed by means of promotion of cooperation between Member States especially 
in quality control of care, especially palliative care, and taking account of the psycho­
social dimension of cancer. Exchanges of experience and the dissemination of awareness 
of best practices recognised at European level should be increased. 
58. Given the encouraging results obtained in the first years of the programme - due to the 
programme having acted as a catalyst and stimulant to Member States' own national 
actions against cancer - adequate resources need to be committed to the action plan in 
order to consolidate the results so far achieved and develop the most important sectors 
for future action, having regard to the programme's objectives. The main purpose of the 
legal and financial instruments advocated is to facilitate or reinforce policies followed 
in the Member States. In addition, the partnership formula, which has proved extremely 
fruitful in motivating and mobilising the various players involved, needs to be pursued 
and developed. 
59. In view of the progress which needs to be made in analyzing and measuring the results 
obtained, special attention needs to be paid to devising a Programme evaluation method 
which takes account of experience acquired and of the recommendations put forward in 
the evaluation report and by the national experts. 
a.l. Cancer registries and epidemiological studies 
60. Cancer registries are an essential component of any rational system for measuring the 
impact of cancer in the general population and an indispensable tool in cancer control 
policies. In particular, cancer registers provide the data necessary for planning future 
measures and the tools for undertaking analytical and descriptive epidemiological 
studies. The data provided by the current registers do not permit all these objectives to 
be attained since they do not offer adequate guarantees in terms of comparability. 
61. The main objectives should be: 
to improve cancer registration; 
to facilitate the collection, notably in collaboration with WHO, of reliable and 
comparable data on the number of cancers so that the disease can be monitored, 
trends identified and European-scale epidemiological studies devised. 
62. Epidemiological studies must be continued, particularly the European cohort studies in 
the context of the European Prospective Investigation into Cancer and Nutrition (EPIC). 
These studies must be supported to make sure that they take place under the best 
auspices: it is essential, from a scientific and public health point of view, that we learn 
from the nutritional and biological data collected from the monitoring of some 350 000 
subjects over a ten-year period. 
30 
63. It is generally accepted that frequent consumption of fresh fruit and vegetables reduces 
the risk of cancers of the digestive and respiratory tract. Although the mechanism is not 
yet completely understood, it appears that some micronutrients and anti-carcinogenic 
substances present in these foods are responsible for the cancer protective effect. 
Epidemiological studies should be directed to this area and should focus on the potential 
for preventing cancer by identifying cancer-protective agents and modifying specific 
dietary factors. 
64. Support must be provided for epidemiological research focused on primary prevention 
and public health intervention, including research focused on risk factors in the 
environment. The strategy should incorporate the following key elements: 
the pursuit of studies on the link between cancer, health and diet; 
the stimulation of epidemiological studies focused on prevention; 
improvement of the fight against carcinogens; 
encouragement for exchanges of information and experience. 
a.2. Specific preventive actions 
65. The risk prevention strategy employed in the first two action plans - a strategy based 
on promotion of the European Code, legislative action at European level and the 
development of exchanges of experience on public information campaigns and school 
health education - has proved very effective. High priority therefore needs to be given 
to preventive actions designed to make Europeans more knowledgeable about the cancer 
risks and thus more inclined to adopt healthy lifestyles. The same applies to actions in 
which the Community can continue to give a spur to national actions. In this context, 
reducing tobacco consumption and excessive alcohol consumption are still the most 
important means of reducing cancer mortality. 
66. According to WHO there are 450 000 tobacco-related deaths in the Union each year. 
Prevention of tobacco consumption therefore remains the priority concern, and 
information campaigns in this field need to be stepped up To reinforce this strategy, 
each Member Slate should decide whnl objet lives il wishes in Mi.uu <utd « omnium, MC 
them to the Commission. The following are among the actions which need to be 
continued and developed: 
alerting at-risk groups such as children and pregnant women to the dangers of 
smoking; a charter could be drawn up for these groups. 
the protection of non-smokers, particularly in public places and at the workplace. 
the development of existing networks (non-smoking towns, non-smoking hospitals, 
clubs for young non-smokers). 
31 
support for implementation of the most effective methods of preventing smoking 
and of helping people to give up smoking. 
support for educational campaigns directed at teachers and adults responsible for 
educating young persons outside the school context. 
closer involvement with information campaigns organised by WHO, particularly 
World No Tobacco Day (31 May each year). 
an upward harmonisation of tobacco prices across the Community. 
encouragement of a cost of living index excluding the price of tobacco, and 
evaluation of the effects of this measure in the countries where it has been 
introduced. 
evaluation of anti-tobacco policies, especially restrictions on direct and indirect 
advertising of tobacco products which have been implemented in Member States. 
a.2.1. Information of the public and specific groups 
67. Information of the public is one of the most effective ways of preventing cancer and 
promoting health; information campaigns should continue to be organised, especially for 
certain key target groups and at key times, such as during the European Weeks against 
Cancer. The main instrument should continue to be the European Code against Cancer, 
adopted by the Committee of Cancer Experts in 1986 and widely distributed throughout 
the Member States since then. This Code could be reviewed in the light of the results 
of current research findings and be tailored to new target groups or specific 
environments such as public places and workplaces. 
68. The aims should be: 
to make Europeans more knowledgeable about cancer prevention, notably through 
diffusion of the European Code, and encourage them to adopt healthier lifestyles; 
to improve the quality of information exchanges between Member States on 
cancer prevention activities; 
to target information campaigns more effectively on specific population groups, 
e.g. health professionals, employers and unions, voluntary organisations and 
teachers. 
69. The approach adopted should include the following key elements: 
the further organisation of European Information Weeks on Cancer Prevention; 
the production of information dossiers accompanied by specific messages for 
particular target groups, e.g. stop-smoking campaigns aimed at women, 
particularly pregnant women; 
32 
the use of the media for broadcasting specific cancer prevention messages and 
tailoring of these messages to the socio-cultural characteristics of individual 
Member States; 
encouragement for studies and surveys designed to evaluate the effectiveness of 
information campaigns; 
support for the organisation of European meetings to facilitate exchanges on the 
most effective methods of informing people about cancer prevention; 
information directed towards doctors, dentists, nurses and other health 
professionals such as pharmacists, and alerting at-risk groups of the importance 
of early detection by seeing a doctor, as recommended in the European Code 
against Cancer. 
a.2.2. Health education 
70. Health education is a lifelong continuing process which begins at the earliest age. 
However, there are two key environments in which health education should be a top 
priority: school and work. Accent should be placed on positive messages such as the 
concept of a finite amount of health which should not be reduced or damaged by 
unhealthy actions such as abuse of licit or illicit substances. 
71. School health education is designed to give children a sense of individual responsibility 
from an early age, i.e. starting in primary school, when they are most receptive to the 
adoption of healthy lifestyles and behaviour. It is also a means of reducing social 
inequalities, in so far as it equips each child with the same tools to prepare for a healthy 
adult life. 
72. Further work should therefore focus on supporting efforts in Member States to devise 
and test a basic school health education programme and a minimum teacher-training 
programme. To this end, exchanges of experience and teaching materials should be 
encouraged, as should the implementation and evaluation of pilot education projects on 
topics such as smoking, nutrition and excessive sun exposure. These activities should 
involve close cooperation not only between the Ministers involved (Ministers of 
Education and Health) but also between all players in the school community (parents, 
teachers and school heads). It would also be appropriate to involve non-governmental 
organisations which are likely to be able to make a significant contribution towards 
promoting and supporting health education in schools, especially in those countries and 
regions where infrastructures and health education initiatives are poorly developed. This 
initiative should be accompanied by rigorous evaluation of both the application of 
teaching approaches and the results achieved. In this way it will be possible to transfer 
the results to other countries. These actions will be primarily carried out in the context 
of the future horizontal programme on health promotion, information, education and 
training, and be complemented and strengthened by specific cancer related actions and 
by actions towards groups such as workers, health personnel, teachers etc. 
33 
73. In order to develop the concept of the "health-promoting school" - a concept introduced 
at the first European Conference on Health Education and Cancer Prevention in Schools, 
held in Dublin as part of the Europe against Cancer Programme - health education, if 
it is to be effective, needs to be applied in a wider context which also takes account of 
the children's socio-cultural environment. The main objectives should be as follows: 
to promote the adoption of healthy lifestyles by the population, and particularly 
by children and young persons; 
to interest parents in health education activities at school and in putting into 
practice the health messages given to the children in school; 
to coordinate actions organised under the Cancer Programme with actions 
organised under other programmes, particularly those from international 
organisations competent in health education matters; 
to stimulate efforts to introduce innovation into the initial and continuing training 
of teachers and others responsible for health education. 
74. Particular emphasis could be placed on the following elements: 
defining and implementing basic health education programmes, with priority being 
given to cancer-related risk factors, particularly smoking and diet; 
interesting and involving children and young persons in health education actions 
and in devising health education messages; 
involving parents and teachers in putting the health education messages into 
practice, both at school (giving children fresh fruit, etc.) and in their home 
surroundings; 
encouraging teacher motivation by organising seminars and conferences and 
providing them with audiovisual teaching materials. 
a.2.3. Training of health personnel 
75. The initiatives taken at European level in the course of the first two action plans have 
had a positive impact on the quality of training at national, regional and local levels and 
have thus helped to reduce the substantial gaps which exist between Member States in 
the training of health personnel. The initiatives were based on the Commission 
Recommendation of 27 November 1989 concerning the training of health personnel in 
the matter of cancer, a Recommendation which remains relevant and which will serve 
as a framework for the promotion of actions directed at doctors, nurses and dentists. The 
activities already begun should be continued so as to ensure that health personnel 
directly involved in cancer prevention and treatment acquire the necessary knowledge 
and skills to enable them to intervene promptly and decisively. 
34 
76. The rapid development of scientific knowledge and the overcrowding of initial training 
programmes mean that development of approaches based on continuous training is 
essential, especially for medical training. 
77. The main objectives can be summarised as follows: 
to improve the knowledge and skills of health personnel (doctors, nurses, dentists) 
in the matter of cancer, in particular its prevention; 
to promote quality training, in particular through the establishment and support of 
training networks (basic training and continuing training) for health personnel 
involved in the fight against cancer; 
to improve the quality of training of other categories of health personnel such as 
pharmacists and data managers; 
to ensure that training also covers the psycho-social aspects of cancer. 
78. The training strategy should incorporate the following key elements at European level: 
the constitution of working parties composed of cancer experts and representatives 
of the health professionals participating in the existing training networks (doctors, 
nurses, dentists); 
consolidation of links with national and regional authorities; 
development at Community level of suitable materials for training health personnel 
in oncology (including primary prevention of cancers) on the basis of consensuses 
defined at European level; use of innovative approaches including remote 
networks and EUROCODE for the rapid exchange of information; 
actions to facilitate the mobility of health professionals between Member States 
for training purposes, in particular between centres of excellence offering high-
quality training courses where this is not covered by existing Community 
programmes; 
support for European training seminars for trainers of health professionals giving 
access to the most significant progress in cancer: prevention (including 
epidemiology), screening and diagnosis. 
a.3. Early detection and systematic screening 
79. Cancer screening remains vitally important if the Programme's overall objective is to be 
met. In the first two action plans the accent was on breast and cervical cancer screening. 
80. The introduction of systematic breast cancer screening for women between ages 50 and 
69 coupled with diagnostic and therapeutic procedures for women presenting a suspect 
image is very important. A network of breast cancer screening pilot projects has been 
35 
set up in 11 Member States. These projects, which in their initial phase set out to 
explore screening and quality assurance programmes and to facilitate exchanges of 
experience, have gradually entered the phase of actual improvement and quality control. 
Quality assurance guidelines for screening of breast cancer were defined at European 
level in 1992 by high level experts. Improvement will come from proper training for all 
categories of personnel involved in breast cancer screening, the involvement of general 
practitioners in order to ensure a high level of participation, and the application of 
European recommendations for high-quality mammography screening. 
81. A high level group established European guidelines for screening for cervical cancer, 
in 1993. A European network of pilot projects was set up at the same time, taking these 
guidelines into account. The pilot projects will need to be accompanied by cytology 
training and quality-assurance training for the health personnel involved. Additionally, 
a common terminology and system of classification will need to be drawn up. 
82. The third action plan must continue to pursue and develop all these actions, which have 
enabled the knowledge and experience acquired by certain Member States to be 
disseminated throughout the European Union and which have given rise to 
recommendations and the implementation of pilot projects at European level, particularly 
in those fields where satisfactory results have been obtained (breast cancer and cervical 
cancer). The field, however, could gradually be extended if the results of cost-benefit 
and feasibility studies for other types of cancer look encouraging (colon, prostate, 
ovaries, cancer of the buccal cavity). 
83. The objectives should be as follows: 
to contribute to the development and establishment of effective screening systems, 
taking account of each Member State's particularities; 
to spread the use of appropriate practices based on the guidelines drawn up at 
European level in the quality assurance protocols for cancer screening and early 
diagnosis; 
to improve the quality of cancer screening through the development of continuing 
training for health personnel. 
84. The strategy should include the following key elements: 
the implementation of the European quality assurance recommendations for breast 
and cervical cancer screening; 
the drafting and diffusion of common terminologies in the specialist fields, 
particularly for cytopathologists in the European Union; 
the promotion of research of European interest on the effectiveness and feasibility 
of screening for certain types of cancer such as the colon, the prostate, the buccal 
cavity and the ovary; 
36 
support for the training of health personnel, in particular in the context of 
European networks of centres of excellence; 
cost-benefit analysis of screening for different types of cancer. 
a.4. Quality control in care (including palliative care) 
85. Care management in the second action plan concentrated on the exchange of information 
among Member States. The importance given to this aspect is justified by the increased 
internal movement within the Community and the need to ensure that standards are 
comparable from one country to another. The development of scientific knowledge and 
the variation in care management procedures across the Community require (as the 
Council indicated in its Resolution of 13.12.1993), the Community to support initiatives 
to allow the identification of best practices in care management and quality control. 
They should be complemented by improvements in the exchange of data via new 
technologies in computing and telecommunications. Clinical research will complete the 
package. All these actions must not infringe the principle of subsidiarity nor interfere 
with the competences of the Member States in the provision of health services. 
86. The principal objectives of this type of action should be, giving due regard to 
subsidiarity and the importance of effective actions at national level: 
the development of networks and mechanisms allowing new methods of care to 
be compared and evaluated, particularly novel therapeutic agents and new 
technologies. It is particularly important to determine why significant differences 
in survival rates can be observed in one region compared with another, and 
sometimes one town with another for different types of cancer (delay in first 
consultation, delay in diagnosis or the commencement of treatment, treatment 
prescribed or executed inadequately). 
The improvement in quality of care offered to the cancer patient including 
palliative care should receive particular attention. This has an important 
Community dimension so far as awareness of the best techniques and methods is 
concerned. The objective of action in this area is to support the definition of 
common terminology and comparison of practice in order to facilitate the transfer 
of this awareness among health professionals. 
for care, the exchange of experience and the dissemination of best practice and 
knowledge at Community level will be useful. 
87. The approach adopted will: 
create a network of care practices of cancer patients, to assist their improvement. 
support European meetings which will define the best achievable practice in care 
management, including palliative care, suitable for dissemination in the Member 
States. 
37 
evaluate the impact of quality control procedures using pilot projects. 
88. In the field of palliative care it would be appropriate to support the implementation of 
the conclusions of a report completed in 1992 by a group of high level experts for the 
"Europe against Cancer" programme.This means: 
periodically evaluating the current state of practice of palliative care in the 
Community; 
defining quality criteria in palliative care through a European consensus; 
improving the training of health personnel in palliative care. 
89. With due respect for subsidiarity and in close cooperation with the competent 
international organisations such as the WHO, the approach will favour: 
support work on the status of palliative care in the European Community; 
the organisation of a European consensus conference on the role of training in 
palliative care in medical studies, and the dissemination of its results in the 
Member States; 
the development of research and studies on the practice of palliative care and the 
implementation of the results in in-service training for health personnel. 
a.5. Contribution to formulation and dissemination of research 
90. As set out in Articles 130f to 130q of the Treaty, responsibility for cancer research rests 
with the relevant activities under the Community's framework programmes for research 
and specifically the Biomedical and Health Research Programme which includes basic 
and clinical research. Measures under this action plan 1995-1999 will thus make a 
supporting contribution to activities under the next proposed Biomedical programme 
covering 1994-1998 and coherence between the two sets of activities will be ensured by 
the Commission. Clinical studies should also be supported by facilitating trans-European 
clinical trials in cases where the number of cases available makes this approach 
desirable. The existing official and informal networks will be used as far as possible to 
ensure the maximum efficiency of action. 
91. The programme will contribute to the identification of needs in cancer research at the 
European level and will support the creation of an inventory of research in progress. 
92. Measures to ensure dissemination of research results will be strengthened by supporting 
scientific evaluation, consensus conferences and exchange of scientific personnel. This 
latter action will be complementary to existing programmes in the field of mobility of 
scientific and university researchers. 
38 
b. Consultation and participation mechanisms 
b.l. Advisory Committee 
93. The experience of the first and second action plans for cancer has clearly demonstrated 
the need for a committee to assist the Commission. In order to permit the fullest 
possible integration in the activities foreseen in this third action plan of the various 
partners, including scientific expertise at the highest level and the national authorities, 
the Commission will propose the creation of an Advisory Committee chaired by the 
Commission comprising representatives of each Member State. The composition of the 
committee should ensure adequate representation of the interests and expertise of the 
national authorities, the health professionals and the non-governmental organisations in 
the field. 
b.2. Expert Group of high level cancer experts 
94. The Commission will be assisted in its work by an Expert Group of leading cancer 
experts. This Expert Group, the members of which will be drawn from the Member 
States, will advise the Commission on the scientific and technical aspects of proposed 
activities. During the first two action plans the Commission was ably assisted by such 
a group in the form of the Committee of leading Cancer Experts. 
b.3. Other groups involved 
95. The Commission will continue to support national coordination committees for the 
cancer programme, where they exist in order to enhance the motivation and involvement 
of the national players.These national committees, the composition and rules of 
procedure of which are wholly determined locally, have proven their worth in helping 
the many different organisations and professions involved in cancer to work more 
closely together at the national level. 
96. During the first seven years of the Community action against cancer the non­
governmental organisations, specifically the associations and leagues against cancer, 
have contributed generously both funds and expertise. In view of the instrumental role, 
in prevention, care and research, played by these organisations the Commission will 
maintain and strengthen its links with them, both through the Advisory Committee 
described above and through direct links with groupings such as the European Cancer 
Leagues. In particular, the leading role in the preparation and execution of the European 
Weeks Against Cancer will remain with them. 
97. The very wide scope of the action against cancer, and the multi-faceted links with other 
aspects of public health, require that the Commission respond flexibly to the needs to 
involve different types of partners. The Commission will ensure coordination between 
actions under this programme and activities in the programmes foreseen in the 
Commission Communication on a framework for public health, and also other relevant 
Community policies. 
39 
c. Evaluation and reports 
98. The evaluation and reporting structure of the action plan will comprise three key 
elements: 
an annual report on the execution of the Programme to Council, the European 
Parliament, the Economic and Social Committee and the Committee of the 
Regions 
an independent peer review evaluation of the major activities and studies funded. 
a global report on the efficiency and effectiveness of projects undertaken under 
the action plan to be submitted to the relevant Institutions by the Commission 
before the end of 1997. 
c.l. Annual report on the execution of the action plan 
99. The purpose of this report is to ensure that the Institutions, and through them all 
concerned, are kept fully informed of the progress of the actions undertaken in the 
context of this action plan. It will include an analysis of projects supported under the 
different actions and also full details of activities in other sectors relevant to cancer. 
c.2. Independent peer review evaluation of the major actions and studies 
supported 
100. Experience acquired in the first two action plans has highlighted the need for more 
effective evaluations of the actions supported by the Programme, both nationally and at 
European level. Such evaluations would facilitate the transferability of results of projects 
from one country to another and hence increase the European added value of the 
programme. In order to introduce effective evaluations of this type, the Commission 
may consult national authorities and other experts in the field in order to establish 
appropriate criteria and protocols. 
c.3. Interim and global reports on the effectiveness of the Action Plan 
101. The Commission will submit an interim report by the end of 1997 which will allow the 
Council and the European Parliament to assess whether any adaptation in the approach 
or the budget of the programme would be appropriate for the last two years of this 
action plan. In preparing this report the Commission will take account of all the reports 
already presented, including those resulting from the first and second action plans. The 
Commission will also submit a final global report at the end of the action plan. 
d. General information activities 
102. In addition to the information actions mentioned in V.a.2.1, the Commission will ensure 
that the results of the most significant actions, studies and evaluations are made 
available to interested parties and the general public. 
40 
VI. RESOURCES 
103. The resources allocated for the first two action plans were of the order of 
ECU 9 to 10 million and ECU 10 to 11 million respectively. The proposed budget for 
the third action plan is summarized in the following table: 
FIELD OF ACTION 
1. Cancer registration 
2. Prevention through action against risk 
factors 
A. Information of the public 
B. Health education 
C. Training of health personnel 
3. Prevention through early detection and 
systematic screening 
4. Studies and surveys in the field of care 
of the cancer patient, inventory and 
dissemination methods 
TOTAL 1993 
BUDGET 
2,1 
2,6 
2,4 
1.7 
L4 
0,6 
10,8 1994 
BUDGET 
2,3 
2,6 
2,4 
1,7 
1,5 
0,8 
11,3 APB 
1995 
(M.ECU/YEAR) 
provisional 
breakdown 
2,0 
2,0 
2,0 
1,5 
2,0 
1,5 
11 1996 1997 1998 1999 
Provisional planning 
12 13 14 14 TOTAL 
1995 
TO 
1999 
64 
41 
FINANCIAL STATEMENT 
1. Tide of operation 
Third action plan against cancer (1995-1999). 
2. Budget heading involved 
Item B3-4304 (combating cancer). 
3. Legal bases 
Treaty establishing the European Economic Community, and in particular Article 2 
thereof. 
Treaty establishing the European Union, and in particular Article 129 thereof. 
Resolution of the Council and the representatives of the Governments of the 
Member States, meeting within the Council, of 7 July 1986 on a programme of 
action of the European Communities against cancer (OJ No C 184, 23.7.1986, 
p. 19). 
Conclusions of the European Council, of 5 and 6 December 1988, concerning the 
implementation of a sustained and concerted information campaign in all the 
Member States, focusing on the prevention, screening and treatment of cancer. 
Decision 90/238/Euratom, ECSC, EEC of the Council and the representatives of 
the Governments of the Member States, meeting within the Council of 17 May 
1990, adopting a 1990 to 1994 action plan in the context of the "Europe against 
Cancer" programme (OJ L 137, 30.5.1990, p. 31). 
Commission report on the evaluation of the effectiveness of action undertaken in 
the context of the "Europe against Cancer" programme (1987-1992) 
(COM(93) 93 final). 
Conclusions of the Council and the Ministers for Health meeting within the 
Council of 27 May 1993. 
Commission communication on the framework for action in the field of public 
health (COM(93) 559 final). 
Council resolution of 13 December 1993 concerning future guidelines for the 
"Europe against Cancer" programme following evaluation of it for the period 1987 
to 1992. 
42 
4. Description of operation 
4.1. General objective: 
A plan of action to combat cancer with a view to reducing deaths from cancer in 
the European Union. 
From the outset, i.e. since the beginning of 1987 when the first action plan was 
launched, the "Europe against Cancer" programme has had the specific objective 
of achieving a 15% reduction in the number of deaths from cancer by the year 
2000, thereby preserving the lives of 150 000 people in Europe. The first action 
plan, which ended in 1989 with a European Year of Information on Cancer, 
focused on informing and raising the awareness of the general public; the 
European Code against Cancer, with its 10 "commandments", constituted one of 
the main instruments for putting the message across. 
Although the results obtained were difficult to quantify, the campaign undoubtedly 
hit home in the sense that people became more alert to cancer-related risk factors; 
the second action plan, covering the period from 1990 to 1994, continued this 
process of raising public awareness, through increased cooperation and 
commitment on the part of all those involved. European cancer information weeks, 
organised each year on a specific topic featured in the European Code, also played 
an important part. At the same time, specific activities were undertaken in the field 
of health education geared to developing a strategy at national and European 
levels. Particular emphasis was placed on the school environment and teaching 
staff. Action was also stepped up in connection with training in cancer prevention 
for health-care workers, with particular reference to general practitioners, dentists 
and nurses. Screening was another area of continuing improvement, entailing the 
setting up of European networks dealing mainly with breast and cervical cancer. 
The third action plan, commencing in 1995, will take account of the results 
achieved; these results were, moreover, evaluated in the report from the 
Commission to the Council, and underpinned a Council resolution of 13 December 
1993 calling on the Commission to prepare a third action plan. In the light of 
experience gained and the results already achieved, the thrust of activities will be 
adjusted accordingly and will be reflected also in the percentage distribution of the 
budget accompanying the draft decision. Continuity will, however, be ensured in 
the shape of ongoing preventive action targeting specific groups such as young 
people and women. 
Intermediate objectives: these will be set during execution of the plan with 
reference to the sectors concerned. For instance: 
43 
in the early detection and screening sector, identification and dissemination 
of the best practices based on the guidelines drawn up at European level in 
the quality assurance protocols. 
in the health education sector, testing of specific basic programmes and a 
minimum cancer training programme for teachers. 
in the training sector, establishment of training networks for health-care 
workers involved in combating cancer; in the nutrition sector, setting of 
qualitative objectives based on the initial findings of the EPIC(1) study. 
Means of achieving the objectives: Increasing emphasis on prevention, 
through concentration on risk factors (informing the public, health education, 
training of health-care workers); 
through early detection and systematic screening; 
through improved collection of data and updating of information on cancer 
mortality and morbidity (cancer registers and epidemiological studies); 
studies and actions concerned with quality of care for cancer patients. 
4.2. Period covered: 1 January 1995 to 31 December 1999. No provision made as 
yet for renewal or extension. 
5. Classification of expenditure 
Non-compulsory expenditure. 
6. TYPE OF EXPENDITURE 
Subsidy for joint financing with other sources in the public and/or private sector (not 
exceeding a given percentage of the total sum required for proposed projects). 
(l) European Prospective Investigation on Cancer nutrition and health. 
44 
7. Financial impact 
7.1. Method of calculating total cost of operation. 
A total sum of ECU 64 million over the period 1995 to 1999 is deemed necessary 
for these activities. The action plan is expected to gather momentum between 1996 
and 1998, easing off in the final year. Moreover, with the programme having been 
in existence for ten years, the growing importance of subsidiarity is now 
recognised; it will be possible for certain actions to develop steadily in enhanced 
conditions in the Member States. 
7.2. Itemised breakdown of cost 
The proposed allocation of resources for the third action plan, shown in the 
following table, would amount to some ECU 13 million per year for the period 
1995 to 1999. The breakdown by field of action for 1994 and 1995 is given as a 
guide. The indicative amounts for subsequent years will have to be confirmed in 
the context of the successive preliminary draft budgets. 
For 1995, the specified sum of ECU 11 million (slightly lower than in 1994) takes 
account of the current budgetary constraints, while remaining consistent with the 
management of the programme. 
45 
HELD OF ACTION 
1. Cancer registers and 
epidemiological 
studies 
2. Prevention through 
action focusing on 
risk factors 
A. Infonning the 
public 
B. Health 
education 
C. Training of 
health-care 
workers 
3. Prevention through 
early detection and 
systematic screening 
4. Studies and activities 
relating to quality of 
care for cancer 
patients; inventory 
and dissemination of 
relevant methods 1993 
BUDGET 
2.1 
2.6 
2.4 
1.7 
1.4 
0.6 
10.8 1994 
BUDGET 
2.3 
2.6 
2.4 
1.7 
1.5 
0.8 
11.3 PDB 
1995 
(million 
I'CU/year) 
indicative 
breakdown 
2.0 
2.0 
2.0 
1.5 
2.0 
1.5 
11 1996 LW7 iV',v-, i •/)') 
Indicative programming 
12 13 14 14 TOTAL 
1995 
to 
1999 
64 
7.3. Indicative schedule of appropriations 
Commitment 
appropriations 
Payment 
appropriations 
1995 
1996 
1997 
1998 
1999 
Subsequent years 
TOTAL 1995 
11 
5 
5 
1 
11 1996 
12 
6 
5 
1 
12 1997 
13 
6 
4.5 
2.5 
13 1998 
14 
8.5 
5 
0.5 
14 1999 
14 
7 
7 
14 TOTAL 
64 
64 
46 
8. Anti-fraud provisions; results of measures taken 
Spot checks carried out on contractors to ascertain that the appropriations have been 
correctly used and to verify the precise details of their use. Similar checks carried out 
in 1993 have proved to be effective. 
9. Elements of cost-eflectiveaess analysis 
9.1. Specific, quantifiable objectives; target population 
Encourage Member States to develop their own means of combating 
cancer, with particular reference to their preventive strategies, intra-
Community cooperation and access to information, through the creation 
of transnational networks (e.g. dobalink network developed at 
Community level allowing rapid utilisation of data on a large scale. 
Targeting of new population groups, especially those at high risk: 
pregnant women, children and adolescents. 
Development of European networks (training, screening, quality control) 
geared to enhancing the effectiveness of prevention from the viewpoint 
of both health-care workers and the general public. 
9.2. Grounds for the operation: 
Rational use of the budget appropriation by means of: 
(a) practical application of the principle of subsidiarity in pinpointing the 
measures to be undertaken and jointly financed. Such measures will be 
adopted and implemented at national level with the backing of Health 
Ministries and scientific experts involved. 
(b) identification and selection of projects for joint financing in the fields of 
prevention, health education, public information, training and 
encouragement of cooperation between Member States to combat cancer. 
Such projects will be selected and implemented with the help of the 
national coordinating committees set up in each country, embracing all 
those involved in combating cancer. 
(c) the concept of Community added value which will be pursued through 
coordination of national actions, dissemination of information and 
experience, setting of priorities, enlargement of existing European 
networks, selection of European projects, and motivation and mobilisation 
of all those involved by means of partnership. 
The Commission will be assisted in the implementation of its programme by 
a special committee which will examine a wide range of problems on a regular 
basis and will advise the Commission as to which of the proposed actions 
should be given priority. 
47 
Support for projects carried out in the Member States constitutes the principal 
method of implementing the programme. Selection of priority projects is 
determined largely by the general and intermediate objectives, and the 
implementation of the actions themselves depends also on the quality and 
reliability of the projects submitted to the competent department in the course 
of the year. 
The criteria for selecting projects are: 
compatibility with the objectives and conformity with at least one of the 
stated objectives; 
examination of the Community added value of the project (transnational 
participation, development of a model applicable in other Member States, 
data which may be used in other Member States, etc.); 
presumed effectiveness and viability; 
clarity and justification of requirements; 
population targeted or reached by the action; 
aptness of the methodology used; 
competence and experience of the organisation; 
adequacy of the measure's budget for achieving the objectives; 
support of national partners in the projects; 
objectively defined evaluation. 
9.3. Monitoring and evaluation of the operation 
The operation will be monitored at European level by the committee of experts 
and the Commission, and at national level by the national coordinating 
committees, Ministries of Health and Education, NGOs, and those responsible 
for implementing and conducting the operation. 
The main tools of evaluation are: 
an annual report on the programme's progress, forwarded to the Council, 
the European Parliament, the Economic and Social Committee and the 
Committee of the Regions; 
an independent evaluation of the principal actions and studies subsidised; 
an overall report on the reliability and effectiveness of projects 
implemented under the action plan, to be submitted by the Commission 
to the competent institutions during the second half of 1997. 
48 
Performance indicators selected for the evaluation: 
results and conclusions of meetings of experts; 
estimate of the target population affected, and media impact; 
evaluation of various projects by Commission officials and/or people 
doing work for the Commission (financial and technical aspects); 
analysis of interim reports on planned and funded measures with a view 
to making changes where necessary; 
impact studies by external bodies; 
aptness of the methodology used by the organisers; 
adequacy of the operation's budget for achieving the objectives; 
clarity of the initial objectives; 
competence and experience of the bodies; 
dissemination of the results. 
Proposed method and frequency of evaluation 
Drafting of interim and final reports on the various measures taken in the 
field in question. 
Development of a "standard" action evaluation form, to be forwarded by 
beneficiaries along with their final reports; checking of these forms by 
officials (either within the Commission or in situ). 
9.4. Coherence with financial programming 
Is the operation incorporated in the DCs financial programming for the 
years concerned? Yes. 
10. Administrative expenditure (Part A of the budget) 
Staff assigned solely to the action in question. 
The staffing structure will be maintained. 
49 
ISSN 0254-1475 
COM(94) 83 final 
DOCUMENTS 
EN 05 
Catalogue number : CB-CO-94-093-EN-C 
ISBN 92-77-66457-6 
Office for Official Publications of the European Communities 
LP2985 Luxembourg 
50