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
Date: 1994-02-28
Institutions: European Commission
Subjects: action programme, cancer, cooperation policy, dissemination of information, public awareness campaign, public health

COMMISSION OF THE EUROPEAN  COMMUNITIES 

COM(94) 83  final 
Brussels,  29.03.1994 

94/0105 (COD) 

Proposal  for  a 
EUROPEAN PARLIAMENT  AND COUNCIL  DECISION 

94/0105  (COD) 

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 

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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. 

The budgetary  authority  shall determine the financial resources available for each financial year. 

Article 3 

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 
The President 

For the Council 
The President 

ANNEX 

MEASURES TO BE IMPLEMENTED  IN THE PERIOD  1995 TO 1999 

I.  CANCER REGISTERS AND EPIDEMIOLOGICAL  STUDIES 

1. 

2. 

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). 

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. 

5. 

the  effectiveness  of  cancer  prevention  messages, 

Improving 
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. 

in  particular 

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. 

II 

INTRODUCTION 

CANCER  TRENDS IN THE MEMBER  STATES  OF THE EUROPEAN 
UNION 

III.  OVERVIEW OF ACTIONS ON CANCER ALREADY TAKEN 

AT COMMUNITY LEVEL 

IV  THE EUROPEAN COMMUNITY APPROACH 

a. 
b. 

c. 
d. 

Objectives  and means 
The Public Health  Framework  and the  "Europe against  Cancer" 
programme 
Cooperation  between  Member  States 
Cooperation  with  international  organisations  and third  countries 

V. 

THE THIRD ACTION  PLAN 

a. 

Priority  actions 

15 

16 

20 

24 
24 

25 
27 
28 

29 

29 

Specific  preventive actions 

a.l.  Cancer registries and epidemiological  studies 
a.2. 
a.2.1.  Information  of the public and  specific  groups 
a.2.2.  Health  education 
a.2.3.  Training  of health  personnel 
a.3. 
Early  detection  and  systematic  screening 
a.4.  Quality  control  in care (including  palliative care) 
a.5.  Contribution  to formulation  and dissemination  of research 

30 
31 
32 
33 
34 
35 
37 
. . ..  38 

b. 

Consultation  and participation  mechanisms 

b.l.  Advisory  Committee 
b.2.  Expert  Group of high level  cancer experts 
b.3.  Other groups involved 

c. 

Evaluation  and reports 

c.l.  Annual  report on the execution  of the action  plan 
Independent  peer review  evaluation  of the  major 
c.2. 
actions and  studies supported 
Interim  and global  reports on the  effectiveness 
of the Action  Plan 

c.3. 

d. 

General  information  activities 

VI. 

RESOURCES 

14 

39 

39 
39 
39 

40 

40 

40 

40 

40 

41 

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; 
to increase life  expectancy  without  disability  or sickness; 

(ii) 
(iii)  to  promote  the  quality  of  life  by  improving  general  health  status  and  the 

(iv) 

avoidance of chronic and disabling conditions; 
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. 

43. 

In  order  to  give  patients  throughout  the  Community  rapid  and  simultaneous  access  to 
important  new  medicinal  products  (high  technology  and  biotechnology  medicinal 
products), 
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. 

procedure  was 

a  Community 

coordination 

introduced 

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 
this  measure  in  the  countries  where  it  has  been 
evaluation  of  the  effects  of 
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 
international 
organisations  competent  in health  education matters; 

those  from 

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 

1993 
BUDGET 

1994 
BUDGET 

APB 
1995 
(M.ECU/YEAR) 
provisional 
breakdown 

1996 

1997 

1998 

1999 

Provisional  planning 

TOTAL 
1995 
TO 
1999 

1.  Cancer  registration 

2,1 

2,3 

2,0 

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 

2,6 
2,4 
1.7 

L4 

0,6 

2,6 
2,4 
1,7 

1,5 

0,8 

TOTAL 

10,8 

11,3 

2,0 
2,0 
1,5 

2,0 

1,5 

11 

12 

13 

14 

14 

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 
(1987-1992) 
the  context  of 
(COM(93)  93  final). 

"Europe  against  Cancer"  programme 

the 

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. 

through 

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 
increased  cooperation  and 
process  of  raising  public  awareness, 
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 

1993 
BUDGET 

1994 
BUDGET 

1996 

LW7 

iV',v-, 

i 

•/)') 

Indicative  programming 

TOTAL 
1995 
to 
1999 

PDB 
1995 
(million 
I'CU/year) 
indicative 
breakdown 

2.1 

2.3 

2.0 

2.6 

2.4 

1.7 

2.6 

2.4 

1.7 

1.4 

1.5 

2.0 

2.0 

1.5 

2.0 

0.6 

0.8 

1.5 

1.  Cancer  registers  and 
epidemiological 
studies 

2.  Prevention  through 
action  focusing  on 
risk  factors 
A. 

Infonning  the 
public 
B.  Health 

C. 

education 
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 

10.8 

11.3 

11 

12 

13 

14 

14 

64 

7.3. 

Indicative  schedule  of  appropriations 

Commitment 
appropriations 

Payment 
appropriations 

Subsequent  years 

TOTAL 

1995 

11 

1996 

12 

1997 

13 

1998 

14 

1999 

14 

TOTAL 

64 

1995 

1996 

1997 

1998 

1999 

5 

5 

1 

6 

5 

1 

6 

4.5 

2.5 

8.5 

5 

0.5 

11 

12 

13 

14 

7 

7 

14 

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 
at 
Community  level  allowing  rapid  utilisation  of  data  on  a  large  scale. 

(e.g.  dobalink  network  developed 

transnational  networks 

Targeting  of  new  population  groups,  especially 
pregnant  women,  children  and  adolescents. 

those  at  high  risk: 

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) 

(b) 

(c) 

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. 

health 

education, 

identification  and  selection  of  projects  for  joint  financing  in  the  fields  of 
prevention, 
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. 

information, 

training 

public 

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 
is 
method  of  implementing 
determined 
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  programme.  Selection  of  priority  projects 

intermediate  objectives,  and 

the  general  and 

largely  by 

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  Commission,  and  at  national 

The  operation  will  be  monitored  at  European  level  by  the  committee  of  experts 
and 
the  national  coordinating 
committees,  Ministries  of  Health  and  Education,  NGOs,  and  those  responsible 
for  implementing  and  conducting  the  operation. 

level  by 

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; 

report  on 

reliability  and  effectiveness  of  projects 
an  overall 
implemented  under  the  action  plan,  to  be  submitted  by  the  Commission 
to  the  competent  institutions  during  the  second  half  of  1997. 

the 

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 

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