Cancer screening in the European Union report on the implementation of the Council Recommendation on cancer screening.
Date: 2010-02-24
Institutions: Directorate-General for Health and Consumers
Subjects: cancer, disease prevention, public health, report

Breast Cancer Screening Programmes
in the EU in 2007

Cervical Cancer Screening Programmes
in the EU in 2007

Population-based, Nationwide

Rollout complete

Rollout ongoing

Piloting

Planning

Non-Population-based, Nationwide

Population-based and 
Non-Population-based

No programme

Population-based, Nationwide

Rollout complete

Rollout ongoing

Piloting

Planning

Population-based, Regional

Rollout complete

Rollout ongoing

Piloting

Non-Population-based, Nationwide

Non-Population-based, Regional

Population-based and 
Non-Population-based

No programme

Colorectal Cancer Screening Programmes
in the EU in 2007

L 327/34        Official Journal of the European Union        16.12.2003

Population-based, Nationwide

Rollout ongoing

Piloting

Planning

Population-based, Regional

Piloting

Planning

Non-Population-based, Nationwide

Population-based and 
Non-Population-based

No programme

COUNCIL RECOMMENDATION
of 2 December 2003
on cancer screening
(2003/878/EC)

THE COUNCIL OF THE EUROPEAN UNION,

Having  regard  to  the Treaty  establishing  the  European  Com-
munity, and in particular Article 152(4), second subparagraph,
thereof,

Having regard to the proposal from the Commission,

Having regard to the opinion of the European Parliament,

Whereas:

(1)    Article  152  of  the  Treaty  provides  that  Community
action  is  to  complement  national  policies  and  be
directed  towards  improving  public  health,  preventing
human  illness  and  diseases,  and  obviating  sources  of
danger  to  human  health.  Such  action  shall  cover  the
fight against the major health scourges, by promoting

C a n c e r  s c r e e n i n g  i n  t h e  E u r o p e a n  U n i o n
Report on the implementation of the Council Recommendation on cancer screening

First Report

European Commission

Cover:
Upper left: Breast Cancer Screening Programmes in the EU in 2007
Upper right: Cervical Cancer Screening Programmes in the EU in 2007
Lower left: Colorectal Cancer Screening Programmes in the EU in 2007
Lower right: Council Recommendation of 2 December 2003 on cancer screening (2003/878/EC)

Acknowledgements:
Source, upper left, upper right, lower left: International Agency for Research on Cancer, Lyon, France
Source, lower right: Official Journal of the European Union L 327/34 (16.12.2003)

C a n c e r   S c r e e n i n g   i n   t h e   E u r o p e a n   U n i o n
Report  on  the  implementation  of  the  Council  Recommendation  on  cancer  screening

First Report

Authors 

L. von Karsa 
A. Anttila 
G. Ronco 
A. Ponti 
N. Malila 
M. Arbyn 
N. Segnan 
M. Castillo-Beltran 
M. Boniol 
J.  Ferlay 
C. Hery 
C. Sauvaget 
L. Voti 
P. Autier 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The  preparation  of  this  report  and  the  activities  described  therein  have  received  financial  support  from  the  European 
Commission [grant agreement. No 2004309, European Cancer Network; No. 2004114 (ECN), European Network for Information 
on Cancer (EUNICE), and No. 2006322, European Cooperation on Development and Implementation of Cancer Screening and 
Prevention Guidelines (ECCG)]. 

The information contained in this publication does not necessarily reflect the opinion or the position of the European Commission. 
Neither  the  European  Commission  nor  any  person  acting  on  its  behalf  is  responsible  for  any  use  that  might  be  made  of  the 
following information. 

The presently reported classification of the screening programme status in the Member States of the European Union is based 
on  information  provided  by  official  sources  in  all  of  the  twenty-seven  EU  Member  States.  Special  thanks  are  due  to  the 
permanent representations to the EU in Brussels of the Member States which provided data collected from respective national 
sources and returned filled in questionnaires. Special thanks are also due to the health authorities and screening programmes 
which provided information used in the present report on those Member States from which filled in questionnaires could not be 
obtained prior to finalization of the report.  

Special thanks are also due to the screening professionals and scientists participating in the ECN and EUNICE projects listed in 
Annex 1 who provided additional data and checked the plausibility of the data used in the present report. 

Numerous other persons involved in performance of the ECN and EUNICE projects have contributed to the preparation of this 
report. Their contributions are gratefully acknowledged. 

The comments of Lynn Faulds Wood and Susan Knox who checked the manuscript from the perspective of a cancer patient are 
also gratefully acknowledged. 

The technical support of Ms. Krittika Guinot in the Screening Group and Ms Aurélie Millerat in the Data Analysis and Interpre-
tation Group at IARC is gratefully acknowledged. 

All  of  the  subprojects  receiving  financial  support  from  the  European  Commission  under  the  above-mentioned  contracts  have 
also required co-financing from other sources. This co-financing is also gratefully acknowledged. 

Previous versions of this document were made available on the website of the European Union in June 2008. Errata which have 
been received in the meantime have been corrected in the present, third version. 

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II 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Authors1 

Lawrence von Karsa 
Screening Quality Control Group, International Agency for Research on Cancer, Lyon, France 

Ahti Anttila 
Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland  

Guglielmo Ronco 
Unit of Cancer Epidemiology, Centre for Cancer Epidemiology and Prevention (CPO Piemonte), Turin, 
Italy 

Antonio Ponti 
Unit of Cancer Epidemiology, Centre for Cancer Epidemiology and Prevention (CPO Piemonte), Turin, 
Italy 

Marc Arbyn 
Unit  of  Cancer  Epidemiology,  Department  of  Epidemiology,  Scientific  Institute  of  Public  Health, 
Brussels, Belgium 

Nereo Segnan 
Unit of Cancer Epidemiology, Centre for Cancer Epidemiology and Prevention (CPO Piemonte), Turin, 
Italy 

Nea Malila 
Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland  

Mariana Castillo-Beltran 
Screening Quality Control Group, International Agency for Research on Cancer, Lyon, France 

Mathieu Boniol 
Epidemiology Methods and Support Group, International Agency for Research on Cancer, Lyon, France 

Jacques Ferlay 
Data Analysis and Interpretation Group, International Agency for Research on Cancer, Lyon, France 

Clarisse Hery 
Data Analysis and Interpretation Group, International Agency for Research on Cancer, Lyon, France 

Catherine Sauvaget 
Screening Group, International Agency for Research on Cancer, Lyon, France 

Lydia Voti 
Descriptive Epidemiology Production Group, International Agency for Research on Cancer, Lyon, 
France 

Philippe Autier 
Biostatistics and Epidemiology Cluster, International Agency for Research on Cancer, Lyon, France 

 1 Authors and reviewers serve in their individual capacities as experts and not as representatives of their govern-
ment or any  organization with which they are affiliated. Affiliations are provided for identification purposes only. 

Minor  pertinent  interests  are  not  listed.  These  include  consulting  on  non-regulatory  matters  totaling  less  than 
2−5% of time and compensation, research grants totalling less than 5−10% of the research budget, occasional 
travel grants totalling less than 5−10% of time, and stock holdings valued at less than US$ 10 000 overall. 

 III

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
Address for correspondence 

Dr. Lawrence von Karsa 
European Cancer Network Coordination Office 
Screening Quality Control Group 
International Agency for Research on Cancer 
150 cours Albert Thomas 
F-69372 Lyon cedex 08 / France 
ecn@iarc.fr 

IV 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reviewers2

Rosemary Ancelle-Park 
Direction Générale de la Santé, Paris, France 

Silvina Arrossi 
Centro de Estudios de Estado y Sociedad –CEDES / Consejo Nacional de Investigaciones Científicas y 
Técnicas –CONICET, Buenos Aires, Argentina 

Nieves Ascunce 
Instituto de Salud Publica, Pamplona, Spain 

Marjolein van Ballegooijen 
Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands 

Mireille Broeders 
Radboud University Hospital, Nijmegen, The Netherlands 

Min Dai 
National  Office  of  Cancer  Prevention  and  Control,  Chinese  Academy  of  Medical  Sciences,  Beijing, 
P.R.China 

Mary Heanue 
Descriptive  Epidemiology  Production  Group,  International  Agency  for  Research  on  Cancer,  Lyon, 
France 

René Lambert 
Screening Group, International Agency for Research on Cancer, Lyon, France 

Ji-guang  Li 
China Medical University Cancer Institute,  Shenyang,  P.R.China 

Szilvia Madai3 
Public Association for Healthy People, Budapest, Hungary 

M.Siddiqi 
Cancer Foundation of India, Kolkata, India 

Richard Muwonge 
Screening Group, International Agency for Research on Cancer, Lyon, France 

Florian Nicula 
Institutul Oncologic "I. Chiricuta", Cluj-Napoca, Romania 

Lennarth Nyström 
Department of Epidemiology, Umea University, Umea, Sweden 

Julietta Patnick 
NHS Cancer Screening Programmes, University of Oxford, Oxford, United Kingdom 

Maja Primic-Žakelj 
Epidemiology and Cancer Registry Unit, Institute of Oncology, Ljubljana, Slovenia 

Vitor José Lopes Rodrigues 
Faculdade de Medicina, Universidade de Coimbra, Portugal 

 2  See footnote on page III. 
 3 Owns shares in a company which owns and operates breast units performing breast cancer screening. 

  V

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
Astrid Scharpantgen 
Ministry of Health, Luxembourg 

Sven Törnberg 
Department of Cancer Screening, Oncologic Center, Karolinska Hospital, Stockholm, Sweden 

Hugo de Vuyst 
Infections  and  Cancer  Epidemiology  Group,  International  Agency  for  Research  on  Cancer,  Lyon, 
France 

Chris de Wolf 
Agence pour le développement et évaluation des politiques de santé (ADSAN), Geneva, Switzerland 

Marco Zappa 
Center for Study and Prevention of Cancer (CSPO), Florence, Italy 

 VI 

 
 
 
 
 
PPrreeffaacceess  

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
Preface 

By Androulla Vassiliou, European Commissioner for Health 

Cancer  is  a  major  cause  of  suffering  and  death  in  the  European  Union.  Every  year  around 
3.2  million  Europeans  are  diagnosed  with  cancer;  a  burden  that  is  expected  to  grow  even 
greater due to demographic trends in Europe. But with regular and systematic examinations, 
using  evidence-based  screening  tests  followed  by  appropriate  treatment,  it  is  possible  to 
reduce cancer mortality and improve the quality of life of European citizens who are suffering 
from cancer by detecting cancer at earlier stages, when it is more responsive to less aggres-
sive treatment. This brings benefits not only to the individuals concerned, but through early 
action, screening can help to minimise the economic and social burden of cancer on society 
as a whole. 

The  Council  Recommendation  on  cancer  screening,  adopted  unanimously  by  the  Health 
Ministers of the European Union in December 2003, sets out fundamental principles of best 
practice in early detection of cancer, and represents a shared commitment by Member States 
to implement cancer screening programmes. As this scientific report on the implementation 
of the Council Recommendation shows, this shared commitment is being steadily translated 
into  concrete  action  across  the  Union,  with  many  Member  States  running  or  establishing 
population-based screening programmes for breast, cervical and colorectal cancer. 

These programmes take much time  and effort to implement effectively.  Five years on, we 
are still only around half-way to ensuring that everyone who should be covered according to 
the  Recommendation  actually  is.  Nevertheless,  the  commitment  to  addressing  cancer 
remains,  as  recently  also  reaffirmed  by  both  the  Council  and  the  Parliament,  and  the 
Commission will continue to support Member States in implementing the Recommendation, 
and in tackling cancer more generally. 

The  impact  of  the  Council  Recommendation  on  cancer  screening  throughout  the  European 
Union exemplifies the unique role that the EU can play in cooperation with national govern-
ments,  professional  organisations  and  civil  society  to  maintain  and  improve  the  health  of 
Europe's  citizens.  This  report  provides  a  solid  scientific  reference  point  for  assessing  our 
progress in implementing the Council recommendation on cancer screening. I am confident 
that it will be a valuable document in our continued action against cancer. 

Brussels, May 2008 

  IX

 
 
 
 
 
 
 
 
 
 
 
 
 
Preface 

Maja Primic-Žakelj * 

Population-based cancer screening using evidence-based tests has considerable potential to 
improve  the  health  of  the  population,  provided  that  programmes  are  implemented  cost-
effectively and with high quality. The population-based approach ensures that screening also 
reaches the less fortunate who may be in greatest need of secondary prevention of cancer, 
and  it  also  stimulates  continuous  improvement  in  the  quality  of  diagnostic  and  therapeutic 
services wherever they are provided. The substantial progress resulting from effective imple-
mentation of nationwide, population-based cancer screening programmes makes such efforts 
particularly attractive to policy makers and health professionals seeking to reduce the health 
disparities in the European Union. 

This applies particularly to the Member States which recently acceded to the EU. Despite les-
ser economic resources, many of these countries are facing steeper increases in the burden 
of  cancer  than  elsewhere  in  the  EU,  due  to  more  pronounced  demographic  trends  with 
increasing proportions of the older age groups affected by cancer in the population. In these 
countries,  the  prospect  of  benefiting  from  the  previous  experience  in  other  Member  States 
and the need to make careful choices in allocation of resources for health are of fundamental 
importance. Furthermore, in many of the new Member States, opportunistic screening, with-
out quality assurance and control is using scarce resources intended for public health. Unfor-
tunately, there is benefit, if any, only for a small population group and the effect of this acti-
vity is not reflected in better survival due to earlier cancer detection or in reduced mortality. 

The recent experience in Slovenia in establishing a population-based breast cancer screening 
programme    based  on  the  European  quality  assurance  guidelines  (after  introduction  of  a 
population-based  cervical  cancer  screening  programme  in  2003)  has  demonstrated  that 
adopting  the  right  policy  is  only  the  first  important  step  in  effectively  implementing  cancer 
screening.  As  pointed  out  in  the  EU  guidelines,  achievement  of  high  quality  screening  re-
quires political support, sufficient infrastructure and financing, and supervision. Considerable 
time and  effort  and  additional  financial resources are required  to successfully complete the 
planning and preparatory phase. Approximately five years have expired from the beginning 
of  the  consensus-building  and  planning  process  to  the  start  of  programme  rollout  in 
Ljubljana in April, 2008. The region served by population-based screening will be expanded 
gradually  over  the  next  few  years  in  order  to  take  the  experience  in  each  phase  of  rollout 
into account, and in order to assure cost-effectiveness. By the time the last invitation in the 
first round of screening is sent, approximately nine years will have expired from the begin-
ning  of  planning  to  the  completion  of  nationwide  programme  rollout.  The  present  report 
shows that the length of this process and the scope of activities are typical of the experience 
in other Member States. 

Many persons and institutions have contributed to the efforts leading up to the launch of the 
Slovenian  Breast  Screening  Programme.  Unfortunately,  they  cannot  all  be  mentioned  here. 
Their substantial contributions and efforts are gratefully acknowledged. Although each con-
tribution has been essential, with hindsight, one of the most significant impediments which 
had  to  be  overcome  to  successfully  implement  the  breast  screening  programme  was  the 

 X 

 
 
 
 
 
 
 
 
 
 
scarcity  of  appropriate  professional,  technical  and  scientific  support  for  planning  the  pro-
gramme, for training and supervising the learning organisation which will manage and deli-
ver the screening services, and for establishing the monitoring of performance and the eval-
uation of the impact of screening on the burden of disease in the population. Completion of 
the planning phase and the initiation of programme rollout during the current EU presidency 
in Slovenia would not have been possible without recruitment of a multidisciplinary advisory 
team  experienced  in  population-based  programme  implementation  through  the  Screening 
Quality Control Group at the International Agency for Research on Cancer in Lyon where the 
coordination office of the European Cancer Network is located.  

Since  December  2006  the  Screening  Monitoring  and  Evaluation  Unit  in  the  Dept.  of  Epide-
miology  and  Cancer  Registry  at  the  Institute  of  Oncology  Ljubljana  and  the  Slovenian 
Ministry  of  Health  have  collaborated  with  the  ECN  and  IARC  experts  in  planning  the  pro-
gramme  organisation  and  rollout,  in  establishing  the  procedures  and  protocols,  and  in  pro-
viding  the  requisite  multidisciplinary  training  and  professional  supervision  in  the  start-up 
phase  of  the  Ljubljana  Screening  Unit  and  the  Programme  Coordination  Office  at  the 
Institute of Oncology Ljubljana. 

The importance  of a European advisory capacity for timely and effective implementation of 
population-based  cancer  screening  programmes  has  also  been  pointed  out  at  the  pan-
European conference held in February, 2008, in Brdo, Slovenia: The Burden of Cancer - How 
Can it be Reduced?  The conference took place in the framework of the first Presidency of 
the Council of the European Union held by one of the twelve newly acceded Member States. 
The attending experts and the representatives of the national authorities responsible for the 
health  of nearly 500 million individuals in the EU called for professional, organisational and 
scientific  support  for  Member  States  seeking  to  establish  and  improve  population-based 
screening  programmes,  and  they  pointed  out  the  need  to  make  appropriate  resources 
available for such efforts, including monitoring, evaluation, accreditation and certification of 
services  fulfilling  European  standards.  Given  the  considerable  time  and  effort  required  to 
plan and successfully implement effective cancer screening programmes, and in light of the 
large volume of screening examinations which will be required in the coming years to make 
programmes  of  appropriate  quality  available  to  all  persons  in  the  EU  who  may  benefit,  the 
time has come to take further action at the Community level to make the resources for pan-
European collaboration and cooperation available on a scale which is appropriate to the task. 

Ljubljana, May 2008 

* Head of Epidemiology and Cancer Registry Unit at the Institute of Oncology Ljubljana 

  XI

 
 
  
 
 
 
 
 
 
 
 
Preface 

Peter Boyle *  

Breast, cervical and colorectal cancer are major health burdens in the Member States of the 
European Union. According to the 2006 estimates of the International Agency for Research 
on  Cancer,  331,000  cases  and  90,000  deaths  due  to  breast  cancer,  and  36,500  cases  and 
15,000 deaths due to cervical cancer were reported in women in the EU. Colorectal cancer 
deaths  were  registered  for  68,000  women  and  78,000  men,  and  new  cases  of  colorectal 
cancer  were  reported  in  140,000  women  and  170,000  men.  The  burden  of  disease  is 
particularly  unevenly distributed in the case of  cervical cancer: the proportion of  cases and 
deaths is markedly elevated in all but one of the Member States which acceded to the EU in 
2004 and 2007. 

Experience in the Europe Against Cancer Programme has shown  that the overall burden of 
these cancers in the population and the pronounced disparity between EU Member States in 
the burden of disease could be substantially reduced by implementation of population-based 
screening programmes of appropriate high quality. In 2003, based on the positive results of 
the Europe Against Cancer Programme,  the  Council  of  the  European  Union  recommended 
implementation  of  respective  screening  programmes  in  the  Member  States,  according  to 
European quality assurance guidelines where they exist.  

This  present  report  focuses  on  the  implementation  of  the  Council  Recommendation  on 
Cancer  Screening  in  the  EU,  prepared  four  years  after  adoption,  and  shows  that  Europe 
leads  the  way  world-wide  in  implementation  of  population-based  screening,  with  over  50 
nationwide  programmes  for  breast,  cervical  or  colorectal  cancer  currently  running  or  being 
established  and  over  half  a  billion  examinations,  at  current  levels,  being  performed  over  a 
10-year  period  in  the  EU.  The  lessons  learned  in  Europe  in  managing,  monitoring  and 
improving the quality of screening on such a large scale will be instructive for other regions 
of  world  preparing  to  implement  and  expand  population-based  screening  programmes  in 
coming years. 

Despite  the  progress  demonstrated  in  the  first  report  on  implementation  of  the  Council 
Recommendation  on  Cancer  Screening,  there  is  no  room  for  complacency  in  the  current 
efforts  to  make  population-based  screening  available  to  all  persons  in  Europe  who  may 
benefit.  Furthermore,  substantial  resources  urgently  needed  for  implementation  of  cost-
effective  programmes  are  currently  consumed  by  an  excessive  volume  of  examinations  in 
programmes  which  still  lack  the  population-based  approach  essential  to  adequate  quality 
assurance.  This  is  particularly  true  of  many  cervical  cancer  screening  programmes,  which 
currently  provide  over  one-half  of  all  screening  examinations  performed  in  the  EU.  The 
screening intervals applied in such programmes are commonly much shorter than the 3 to 5 
years recommended in the European guidelines. They are not justified by the natural history 
of  the  disease  and  they  are  frequently  applied  in  non-population-based  programmes  which 
do not identify and personally invite all eligible women in the target population. This leads to 
overuse of screening by a portion of the target population accustomed to consuming health 
resources,  and  underuse  by  many  women  who  would  be  even  more  likely  to  benefit  from 
attending  screening.  Many  more  lives  could  be  saved  and  additional  resources  could  be 

 XII 

 
 
 
 
 
 
 
 
 
 
mobilized for further implementation of programmes of appropriate quality, if Member States 
would  take  further  action  to  follow-up  on  the  Council  Recommendation  by  converting 
opportunistic  screening  programmes  to  the  population-based  approach  with  personal 
invitation of each eligible person to attend screening at the appropriate time. 

Continuously improved quality assurance guidelines based on scientifically sound and applic-
able  screening  standards  are  essential  to  assuring  that  population-based  programmes  of 
appropriate  quality  and  effectiveness  are  available  to  all  persons  who  may  benefit  from 
cancer screening. The International Agency for Research on Cancer (IARC) provides scientific 
and  technical  support  for  continued  development  of  the  European  guidelines  for  quality 
assurance of breast, cervical and colorectal cancer screening. These activities, which are co-
funded  by  the  EU  Health  Programme,  are  coordinated  by  the  Screening  Quality  Control 
Group which also provides the coordination office of the European Cancer Network in which 
the  former  European  Cancer  Screening  Networks  established  under  the  Europe Against 
Cancer Programme have been consolidated. The fundamental principles of quality assurance 
elucidated  in  the  EU  guidelines,  and  the  methodological  approaches  to  their  widespread 
application  in  nationwide  screening  programmes  also  apply  to  settings  in  which  resource 
limitations  require  different  test  procedures,  or  a  significantly  lower  number  of  screening 
tests per person, such as once-in-a-lifetime screening for cervical cancer by visual inspection. 
The commitment of the Agency to international collaboration in the further development and 
application  of  the  European  screening  guidelines  is  therefore  also  an  important  part  of  the 
efforts  of  the  Agency  to  provide  scientific  and  technical  support  for  regions  of  the  world  in 
which  implementation  of  cancer  screening  programmes  is  less  developed  than  currently  is 
the case in Europe. 

The first report on implementation of the Council Recommendation on Cancer Screening also 
reflects the crucial importance of providing adequate sustainable resources for planning and 
piloting population-based cancer screening programmes before they are rolled out across a 
country.  The  current  bottleneck  resulting  from  the  scarcity  of  multidisciplinary  teams 
experienced  in  the  complex  task  of  assisting  countries  preparing  to  implement  population-
based cancer screening programmes should be a matter of concern for policy makers around 
the world. Approaches to alleviate this situation will be addressed by the Agency in the pilot 
programme  for  accreditation  and  certification  of  breast  cancer  screening,  diagnosis  and 
management  currently  being  developed  at  the  request  of  the  European  Commission.  The 
programme will be coordinated by the Screening Quality Control Group in collaboration with 
the European Cooperation for Accreditation with financial support of the European Union. 

Lyon, May 2008 

* Director, International Agency for Research on Cancer 

 XIII

 
 
 
 
 
 
 
 
 
 
Table of Contents 

Executive summary 

Introduction 

Methodology 

Questionnaire 

Responding countries and additional data sources 

Definitions 
Screening programmes 
"Programme" vs. "non-programme" screening 
Organised screening 
Population-based screening 
Country implementation status 

Quantitative description of screening implementation 
in the EU Member States 

Breast cancer screening 
Policy consensus 
Number of persons affected by screening 
Programme implementation status 
Variation between Member States 
Volume of programme screening 
Volume of non-programme screening 

Cervical cancer screening 
Policy consensus 
Number of persons affected by screening 
Programme implementation status 
Variation between Member States 
Volume of programme screening 
Volume of non-programme screening 

Colorectal cancer screening 
Policy consensus 
Recommended screening method (FOBT) 
Novel screening tests still under evaluation (Endoscopy) 
Number of persons affected by screening 
Programme implementation status 
Variation between Member States 
Volume of programme screening 
Volume of non-programme screening 

Page 

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9

10

11

13

14
14
14
15
15
15

16

16
16
17
17
17
18
18

18
18
19
19
20
20
20

21
21
21
21
21
22
22
23
23

1 

2 

2.1 

2.2 

2.3 
2.3.1 
2.3.1.1 
2.3.1.2 
2.3.1.3 
2.3.2 

3 

3.1 
3.1.1 
3.1.2 
3.1.3 
3.1.4 
3.1.5 
3.1.6 

3.2 
3.2.1 
3.2.2 
3.2.3 
3.2.4 
3.2.5 
3.2.6 

3.3 
3.3.1 
3.3.1.1 
3.3.1.2 
3.3.2 
3.3.3 
3.3.4 
3.3.5 
3.3.6 

 XIV 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4 

4.1 

4.2 

4.3 

4.4 

4.5 

4.6 

5 

5.1 

5.2 

5.3 

5.4 

5.5 

5.6 

6 

7 

Qualitative information on implementation of cancer 
screening in the EU Member States 

Implementation of cancer screening programmes 

Registration and management of screening data 

Monitoring 

Training 

Compliance 

Introduction of novel screening tests 

Discussion 

Scope of the first report on implementation of the Council 
Recommendation on cancer screening 

Impact of the Council Recommendation on screening 
policies in the EU Member States 

Current disparity in implementation of cancer screening in 
the EU 

Community added value through transition to population-
based screening programmes 

Barriers to and prospects for further progress 

Recommendations  

Conclusions 

References 

Figure 1 a 

Proportion of Deaths in the EU due to Cancer in 2006 

Figure 1 b  Cases of Breast, Cervical and Colorectal Cancer in the EU in 2006 

Figure 1 c  Deaths due to Breast, Cervical and Colorectal Cancer in the EU in 2006 

Figure 2 a  Breast cancer incidence in the EU Member States 2006 

Figure 2 b  Breast cancer mortality in the EU Member States 2006 

Figure 2 c 

Cervical cancer incidence in the EU Member States 2004 

Figure 2 d  Cervical cancer mortality in the EU Member States 2004 

Figure 2 e  Colorectal cancer incidence in women in the EU Member States 2006 

Figure 2 f 

Colorectal cancer mortality in women in the EU Member States 2006  

Figure 2 g  Colorectal cancer incidence in men in the EU Member States 2006  

Figure 2 h  Colorectal cancer mortality in men in the EU Member States 2006 

24

25

25

25

26

26

26

27

27

27

29

30

31

32

33

34

40

41

41

42

43

44

45

46

47

48

49

 XV

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Figure 3 a  Distribution of Breast Cancer Screening Programmes Based on Mammo-

graphy in the EU in 2007 

Figure 3 b  Number  of  EU  Member  States  by  Type  and  Status  of  Breast  Screening 

Programmes 2007 

Figure 3 c 

50-69-year-old Women in the EU by Type and Status of Breast Screening 
Programmes 2007 

Figure 4 a  Distribution  of  Cervical  Screening  Programmes  based  on  Cervical 

Cytology in the EU in 2007 

Figure 4 b  Number of EU Member States by Type and Status of Cervical Screening 

Programmes 2007 

Figure 4 c 

30-60-year-old Women in the EU by Type and Status of Cervical Scree-
ning Programmes 2007 

Figure 5 

Figure 6 

Distribution  of  Colorectal  Cancer  Screening  Programmes  based  on  the 
Faecal Occult Blood Test in the EU in 2007 

Distribution of Colorectal Cancer Screening Programmes based on Novel 
Screening Tests still under Evaluation (Endoscopy) in the EU in 2007 

Figure 7 a  Number  of  EU  Member  States  by  Type  and  Status  of  Colorectal  Cancer 

Screening Programmes 2007 

Figure 7 b 

50-74-year-old  Women  and  Men  in  the  EU  by  Type  and  Status  of 
Colorectal Cancer Screening Programmes 2007 

Table 1 

Burden  of  Breast,  Cervical  and  Colorectal  Cancer  in  Women  in  the  EU 
Member States 

Table 2  

Burden of Colorectal Cancer in Men in the EU Member States 

Table 3 a 

Table 3 b 

Table 4 a 

Table 4 b 

Table 5 a 

Table 5 b 

Breast Screening Programmes in the EU Member States 2007: Programme 
type, country implementation status and estimated no. of 50-69-year-old 
women in national target populations 

Annual volume of breast cancer screening programmes in the EU Member 
States 2006: Women personally invited, women screened, screening inter-
val,  non-programme  examinations  and  total  size  of  national  target 
populations by programme status 

Cervical  Cancer  Screening  Programmes  in  the  EU  Member  States  2007: 
Programme type, country implementation status and estimated no. of 30-
60-year-old women in national target populations 

Annual volume of cervical cancer screening programmes in the EU Mem-
ber  States  2006:  Women  personally  invited,  women  screened,  screening
interval,  non-programme  examinations  and  total  size  of  national  target 
populations by programme status 

Colorectal Cancer Screening Programmes in the EU Member States 2007:
Programme type, country implementation status and estimated no. of 50-
74-year-old persons in national target populations 

Annual  volume  of  colorectal  cancer  screening  programmes  in  the  EU 
Member  States  2006:  Women  and  men  personally  invited,  women  and
men screened, screening interval, non-programme examinations and total 
size of national target populations by programme status 

Table 6 

Number  of  Persons  attending  Breast,  Cervical  and  Colorectal  Cancer
Screening  Programmes  in  the  European  Union  in  2007  by  Target  Cancer 
and Programme Type 

50

51

51

52

53

53

54

55

56

56

58

59

60

62

64

66

68

70

72

 XVI 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Annex 1 

ECN & EUNICE Participants 

Annex 2 

Council Recommendation of 2 December 2003 on Cancer Screening 

Annex 3 

Questionnaire  on  implementation  of  cancer  screening  in  the  EU  member 
states, sent in May 2007 by by European Commission, Directorate-General
for  Health  and  Consumers  to  the  EU  representations  of  the  27  Member 
States 

Annex 4 

Non-exhaustive list of relevant actions taken by individual Member States 
since  2003,  the  year  in  which  the    Council  Recommendation  on  Cancer
Screening was adopted 

Annex 5 

Qualitative  feedback  from  the  Member  States  on  implementation  of  the
Council Recommendation 

Annex 6 

Examples of effective implementation of screening programmes in the EU

Annex 7 

Websites  of  Screening  Programmes  in  Europe  collected  in  the  EUNICE
project 

Annex 8 

List of abbreviations 

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131

135

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EExxeeccuuttiivvee  SSuummmmaarryy  

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

Executive Summary  

Rationale of the Council Recommendation on Cancer Screening 

After circulatory disease, cancer is the second largest cause of death in the European Union, account-
ing  for  two  out  of  ten  deaths  in  women  and  three  out  of  ten  deaths  in  men  in  2006.  Substantial 
proportions  of  the  cancer  deaths  in  the  EU  are  attributable  to  breast,  cervical  or  colorectal  cancer. 
According to 2006 estimates of the International Agency for Research on Cancer, over 250,000 deaths 
due to these cancers in men and women were reported in the European Union (Fig. 1). The annual 
rates of these cancers vary widely across the EU, reflecting a substantially elevated health burden in 
many  Member  States  (Fig.  2,  Tables  1  and  2).  Regular,  systematic  examination  of  predominantly 
asymptomatic individuals of average risk and of appropriate age using evidence-based screening tests 
followed by appropriate treatment has the potential to prevent many deaths due to these cancers and 
thereby significantly reduce the burden of disease in the population [18-20]4.  

A  large  body  of  knowledge  on  implementation  of  cancer  screening  programmes  has  been  acquired 
through the screening networks established under the Europe Against Cancer programme which have 
been consolidated under the current EU Health Programme in the European Cancer Network. The EU 
networks have shown that the potential benefit of cancer screening may only be achieved if quality is 
optimal at every step in the screening process which includes identification and personal invitation of 
the  target  population,  performance  of  the  screening  test  and,  if  necessary,  diagnostic  work-up  and 
treatment of screen-detected lesions, and aftercare. Screening is performed on predominantly healthy 
persons;  comprehensive  quality  assurance  is  also  required  to  maintain  an  appropriate  balance 
between  benefit  and  harm  in  the  large  numbers  of  persons  eligible  to  attend  cancer  screening 
programmes. Achieving and maintaining high quality at every step in the screening process requires 
an  integrated,  population-based  approach  to  health  service  delivery.  This  approach  is  essential  in 
order  to  make  screening  accessible  to  those  in  the  population  who  may  benefit  and  in  order  to 
adequately monitor, evaluate and continuously improve performance [14, 15, 22, 33]. 

On  2  December  2003  the  Health  Ministers  of  the  European  Union  unanimously  adopted  a  recom-
mendation  on  cancer  screening  based  on  the  developments  and  experience  in  the  Europe  Against 
Cancer programme [11, Annex 2]. The Recommendation of the Council of the European Union spells 
out fundamental principles of best practice in early detection of cancer and invites EU Member States 
to take common action to implement national cancer screening programmes with a population-based 
approach  and  with  appropriate  quality  assurance  at  all  levels,  taking  into  account  European  quality 
assurance guidelines for cancer screening, where they exist. Updated and expanded EU guidelines for 
breast  [14]  and  cervical  cancer  screening  [15]  have  recently  been  published  by  the  European 
Commission; comprehensive European guidelines for quality assurance of colorectal cancer screening 
are currently in preparation.  

Methodology of the present report 

The present report on implementation of the Council Recommendation is based on a written survey of 
the  27  Member  States  conducted  by  the  European  Commission  Directorate-General  for  Health  and 
Consumers in the second half of 2007 (Annex 3) and supplemented by information obtained directly 
from  health  authorities  and  screening  programmes  in  the  Member  States  as  well  as  in  two  pan-
European projects in the EU Health Programme dealing with monitoring, evaluation and quality assur-
ance  of  cancer  screening  (European  Cancer  Network  –  ECN,  and  European  Network  for  Information 

 4  Evidence-based  screening  tests  currently  recommended  by  the  Council  of  the  European  Union:  pap  smear 
screening (cervical cytology) for cervical cancer precursors starting not before the age of 20 and not later than 
the  age  of  30  years;  mammography  screening  for  breast  cancer  in  women  aged  50  to  69  years  in  accordance 
with  European  guidelines  on  quality  assurance  in  mammography  screening;  faecal  occult  blood  screening  for 
colorectal cancer in men and women aged 50 to 74 years. 

1

1 
 
 
 
 
 
 
 
                                                 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

on Cancer - EUNICE). The latest population statistics were obtained from EUROSTAT, or from national 
sources if more recent data was available. Filled in questionnaires were received from twenty of the 
Member States by December 2007. Additional data was solicited from health authorities and screening 
programmes in the Member States from which filled in questionnaires were not available. Data from 
the  ECN  and  EUNICE  projects  was  used  to  check  the  plausibility  of,  and  to  expand  the  data  base. 
Interim results of the present report were presented at two pan-European meetings which have taken 
place in the framework of the Slovenian presidency of the Council of the European Union. Up to May 
2008  additional  and  updated  information  was  received  from  several  Member  States,  including  two 
additional filled in questionnaires, and data from the remaining five Member States from which filled in 
questionnaires  had  not  been  received.  The  status  of  cancer  screening  programmes  reported  in  the 
present  first  report  on  implementation  of  the  Council  Recommendation  on  Cancer  Screening  is 
therefore  based  on  official  information  provided  by  all  of  the  27  Member  States.  The  report  will  be 
regularly  revised  to  provide  a  basis  for continued  efforts  to  expand  and  update  the  follow-up  of  the 
Council Recommendation at the  level of the European Union.  

Breast cancer screening in the EU 

In  2007  more  than  59  million  women  in  the  EU  were  of  the  target  age  for  breast  cancer  screening 
based  on  mammography  specified  in  the  Council  Recommendation  (50-69  years).  Four  out  of  10 
women in this age group in the EU (41%) were targeted for breast cancer screening by 11 Member 
States in which nationwide rollout of population-based programmes was complete in 2007. A slightly 
higher  proportion  of  the  women  in  this  age  group  in  the  EU  (44%)  was  targeted  for  breast  cancer 
screening  by  the  seven  Member  States  in  which  nationwide  rollout  of  population-based  breast 
screening programmes was ongoing in 2007. Non-population-based programmes were running in five 
Member  States,  one  of  which  was  also  piloting  population-based  programmes.  No  screening  pro-
gramme  based  on  mammography  was  running  or  being  established  in  only  one  Member  State  in 
2007. 

Women outside the age range 50-69 years were also eligible to attend breast screening programmes 
in a number of Member States in 2007. In the Member States which have adopted a population-based 
approach  for  breast  cancer  screening,  the  smallest  target  age  range  is  50-59  years  and  the  largest 
age  range  is  40-74  years.  The  limits  of  the  target  age  for  breast  cancer  screening  in  the  EU  varied 
between  40  and  75  years  in  2007.  The  lowest  age  targeted  was  less  than  50  years  in  8  Member 
States; the highest age targeted was over 69 years in the same number of Member States. In 2007, 
over  64  million  women  in  the  EU  were  targeted  for,  and  approximately  12  million  women  attended 
breast cancer screening programmes based on mammography. 

Cervical cancer screening in the EU  

Nearly 109 million women in the EU in 2007 were in the age range 30-60 years which corresponds to 
the  minimum  target  age  recommended  in  the  recently  published  second  edition  of  the  European 
Guidelines  for  Quality  Assurance  in  Cervical  Cancer  Screening  [15].5  Five  out  of  ten  30-60-year-old 
women in the EU (51%) were targeted for cervical cancer screening in the 17 Member States which 
had adopted policies aiming for implementation of population-based screening programmes. Two out 
of  10  women  in  this  age group  in  the EU  (22%)  were  targeted for  cervical  cancer  screening  by  the 
population-based programmes which were rolled out nationwide in seven Member States in 2007. Five 
out  of  10  women  in  this  age  group  in  the  EU  (47%)  were  targeted  by  cervical  cancer  screening 
programmes  in  the  12  Member  States  which  have  adopted  non-population-based  policies.  Four 
Member  States  had  dual  programme  type  or  status  and  two  Member  States  were  not  running  or 
establishing cervical screening programmes in 2007. 

 5 The current second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening recom-

mends 30-60 years or 30-65 years as the minimum age group to target for cervical cancer screening.  

2 

2 
 
 
 
 
 
                                                 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

The full age range targeted for cervical cancer screening varied considerably across the EU in 2007; 
the  lowest  age  to  begin  screening  was  less  than  30  years  in  19,  and  the  highest  age  targeted  for 
screening was over 60 years in 16 Member States.6 If women outside the 30-60-year-old age range 
are taken into account, approximately 146 million women were targeted by cervical cancer screening 
programmes  which  were  running  or  being  established  in  the  EU  in  2007.  Approximately  32  million 
women in the EU attended screening programmes based on cervical cytology in 2007. 

Colorectal cancer screening in the EU 

Approximately  136  million  women  and  men  in  the  EU  in  2007  were  in  the  target  age  group  for 
colorectal cancer screening specified in the Council Recommendation (50-74 years). Over four out of 
10 women and men (43 %) in this age group in the EU were targeted for colorectal cancer screening 
by the 12 Member States which have adopted policies aiming for implementation of population-based 
programmes. Three out of 10 women and men (34%) in this age group in the EU were targeted for 
colorectal  cancer  screening  by  the  five  Member  States  rolling  out  population-based  programmes 
nationwide in 2007. Approximately three out of 10 women and men (27%) in this age group in the EU 
were  targeted  for  colorectal  cancer  screening  by  the  seven  Member  States  which  have  adopted 
policies  aiming  for  implementation  of  non-population-based  programmes.  No  screening  programmes 
were running or being established in eight Member States in 2007. If women and men outside the age 
range  50-74  years  are  taken  into  account,  approximately  107  million  individuals  were  targeted  by 
colorectal cancer screening programmes which were running or being established in the EU in 2007. 

The age range targeted for colorectal cancer screening varied considerably across the EU. Colorectal 
cancer screening began at ages above 50 years in screening programmes based on the faecal occult 
blood test (FOBT) in three Member States, and in programmes based on endoscopy in two Member 
States.  The  oldest  eligible  age  to  attend  FOBT-based  colorectal  cancer  screening  was  less  than  74 
years  in  programmes  in  nine,  and  more  than  74  years  in  seven  Member  States.  In  2007, 
approximately  12  million  women  and  men  attended  colorectal  cancer  screening  programmes  in  the 
EU. In more than nine out of 10 cases (approximately 94%), screening was based on the faecal occult 
blood  test  (FOBT),  which  is  the  evidence-based  screening  method  currently  recommended  by  the 
Council. The other screening tests were based on endoscopy (flexible sigmoidoscopy or colonoscopy), 
a novel test method which is still under evaluation. 

Impact of the Council Recommendation 

Four years after its adoption, most Member States have acted on the Council Recommendation, and 
most  Member  States  intend  to  undertake  further  action  where  implementation  is  not  yet  complete. 
The scale of these activities underlines the substantial impact which recommendations of the Council 
of the European Union can have on the health of the European population. 

A  long-term  translational  phase  is  essential  to  successfully  plan,  pilot  and  rollout  population-based 
cancer screening programmes across an entire country, and particularly also across several countries. 
The  time  frame  depends,  to  a  large  extent,  on  the  professional  and  organisational  capacity  which 
must be developed to successfully perform, monitor and evaluate high quality services integrating all 
steps in the screening process. This activity not only entails coordination of complex communication 
and  training,  but  also  integration  of  multidisciplinary  teams  into  the  diagnosis  and  treatment  of 
screen-detected  lesions,  and  integration  of  cancer  registration  and  cancer  registries  into  the 
monitoring and  evaluation  of  programme  performance. Even  in countries  with  relatively small  target 
populations,  the  magnitude  of  the  task  can  be  substantial,  compared  to  initially  available  resources. 
Successful  preparation  and  completion  of  the  nationwide  implementation  process  may  require  ten 
years or more.  

 6 See footnote on page 20. 

3

3 
 
 
 
 
 
 
 
                                                 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

It  is  for  this  reason  that  the  full  impact  of  the  Council  Recommendation  on  the  implementation  of 
breast,  cervical  and  colorectal  cancer  screening  programmes  in  the  EU  cannot  be  assessed  at  this 
time.  Nevertheless,  the  present  report  documents  considerable  activities  in  the  EU  Member  States 
aimed  at  following  through  on  the  Council  Recommendation.  Approximately  55  million  examinations 
were performed on persons attending screening programmes for breast, cervical or colorectal cancer 
in 26 Member States in 2007. A substantial number of these examinations (approximately 23 million) 
were provided by population-based screening programmes. Given the less widespread implementation 
of population-based cancer screening programmes in 2003, it is unlikely that this substantial volume 
of  screening  in  the  EU  would  have  been  achieved  in  the  absence  of  the  Council  Recommendation. 
Although currently available data is non-exhaustive, over 70 complex actions in the 27 Member States 
specifically  aimed  at  implementation  of  screening  programmes  have  been  recorded  since  2003,  the 
year  in  which  the  Council  Recommendation  was  adopted.  Although  all  of  these  actions  have  been 
taken as a result of decisions at the national or regional level, and many actions were set in motion 
prior  to  adoption  of  the  Council  Recommendation,  the  discussion  leading  up  to  adoption  of  the 
Recommendation and the pan-European exchange between policy makers and experts stimulated by 
this  clear  Community  health  policy  are  likely  to  have  facilitated  the  adoption  and  implementation  of 
many of the respective actions (see Annex 4). 

Furthermore,  the  large  numbers  of  EU  Member  States  which  are  currently  running  or  establishing 
population-based  breast,  cervical  and  colorectal  cancer  screening  programmes  (N=22,  17,  and  12, 
respectively)  indicate  that  four  years  after  adoption  of  the  Council  Recommendation  there  is  sub-
stantial  agreement  between  the  Member  States  in  the  enlarged  EU  and  the  Council  on  the  health 
policy priority of establishing cancer screening programmes of appropriate quality. The scale of these 
activities  underlines  the  substantial  impact  which  actions  at  the  Community  level  can  have  on  the 
health of Europe's citizens. 

Current disparity in implementation of cancer screening in the EU 

Despite  widespread  agreement  among  the  Member  States  on  the  importance  of  population-based 
screening programmes as a tool of cancer control, considerable effort will be required over the coming 
years  to  successfully  implement  current  policies  and  to  overcome  existing  barriers  to  programme 
implementation  throughout  the  EU.  This  is  reflected  in  the  numbers  of  Member  States  in  2007  in 
which  nationwide  rollout  of  population-based  breast,  cervical  and  colorectal  cancer  screening  pro-
grammes was still ongoing (N=7, 3 and 5 Member States, respectively) or had yet to begin because 
screening  programmes  were  currently  regionally  limited  or  only  in  the  piloting  or  planning  phase 
(N=4, 7 and 5 Member States, respectively) or because no programme policies of any type for breast, 
cervical or colorectal cancer had been adopted (N=1, 2, and 8 Member States, respectively).  

Community added value of transition to population-based screening programmes 

Non-population-based breast, cervical and colorectal cancer screening programmes are still conducted 
in 5, 12 and 7 Member States, respectively, which currently target over 100 million women and men in 
the  EU  for  145  million  examinations  per  respective  round  of  screening.  Most  of  the  examinations 
offered  in  non-population-based  programmes  are  for  cervical  cancer  screening  (89  million)  and 
colorectal cancer screening (48 million). Transformation of these programmes to the population-based 
approach,  with  quality  assurance  at  all  appropriate  levels  has  the  potential  to  substantially  improve 
the accessibility, effectiveness and the cost-effectiveness of the respective services. At the same time, 
substantial  numbers  of  unnecessary  screening  examinations  could  be  avoided  by  adhering  to  the 
interval for cervical cancer screening recommended in the European guidelines (3-5 years). 

4 

4 
 
 
 
 
 
 
 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

Barriers to and prospects for further progress 

The  current  need  for  additional  efforts  to  monitor  and  improve  screening  services  provided  to  the 
population  in  the  EU  is  also  reflected  in  the  qualitative  information  provided  by  22  Member  States 
from  which  filled  in  questionnaires  were  received  for  the  present  report.  Whereas  eight  out  of  10 
Member States reported that they followed at least two out of three items in the survey dealing with 
most  of  the  principles  specified  in  the  Council  Recommendation,  this  level  of  compliance  was  only 
reported  by  4  out  of  10  Member  States  for  items  dealing  with  monitoring  (36%)  and  scientific 
evaluation prior to introduction of novel screening tests (41%). Furthermore, a high proportion of the 
Member States (82%) reported that they follow the recommendation to provide human and financial 
resources to assure appropriate organisation and quality control. Yet only 41% of the Member States 
indicated that the resources being provided for these important tasks are satisfactory (Annex 5). 

The  results  of  the  present  implementation  report  were  discussed  at  the  recent  Slovenian  EU 
Presidency Conference held on 6-7 February 2008 in Brdo.7 The attending policymakers and experts in 
cancer  prevention  from  across  the  EU  noted  that  at  current  levels,  over  500  million  breast,  cervical 
and colorectal cancer screening examinations will be performed in the EU over the next 10 years. The 
great  potential  of  such  a  large  effort  to  reduce  the  burden  of  disease  through  earlier  detection  and 
treatment  of  cancer  was  widely  acknowledged.  However,  due  to  a  lack  of  reliably  collected  and 
regularly  reported  information,  too  little  is  known  at  the  Community  level  about  the  quality, 
effectiveness  and  cost-effectiveness  of  this  activity.  Regular,  systematic  monitoring,  evaluation  and 
EU-wide  status  reporting  would  promote  the  exchange  of  information  on  successful  developments 
between Member States and would identify weak points requiring improvement. 

Although the current annual volume of screening examinations in the EU is considerable, this volume 
is  less  than  one-half  of  the  minimum  annual  number of  examinations  that  would  be  expected  if  the 
screening  tests  specified  in  the  Council  Recommendation  were  available  to  all  EU  citizens  of 
appropriate age (approximately 125 million examinations per year). Furthermore, less than one-half of 
the current volume of examinations (41%) is performed in population-based programmes. However, a 
population-based approach is necessary to implement comprehensive quality assurance. 

There was broad consensus between policymakers and experts attending the Slovenian EU Presidency 
Conference that the present situation underlines the need for further efforts at the European level to 
facilitate implementation of the Council Recommendation.  

Despite  the  need  for  further  efforts,  the  substantial  progress  made  in  the  implementation  of  cancer 
screening programmes in the EU since adoption of the Council Recommendation on Cancer Screening 
should not be overlooked. The positive experience with the Council Recommendation in encouraging 
successful implementation of complex population-based programmes reaching large segments of the 
European  population  with  highly  specialized  multidisciplinary  services  integrating  a  broad  range  of 
health care providers, regulators and other institutions should be taken into account in future efforts 
to improve the control of cancer and other chronic disease in the EU. 

In  particular,  future  Community  efforts  should  recognize  the  importance  of  a  translational  phase 
permitting appropriate integration of new preventive or therapeutic strategies into existing health care 
systems and programmes. Furthermore, the effectiveness of appropriately integrated strategies under 
“real  life”  conditions  should  be  demonstrated  before  new  programmes  or  modifications  of  existing 
programmes  are  considered  to  be  fully  established. Pan-European  collaboration  in  such  translational 
efforts  has  the  potential  to  accelerate  health  improvements  across  the  EU  by  avoiding  unnecessary 
duplication of effort and by focusing available resources on common problems.  

 7 The increasing burden of cancer - How can it be reduced?  European  conference  held  in  Brdo,  Slovenia,  6-8 

February 2008, under the auspices of the Slovenian Presidency of the Council of the European Union 

5

5 
 
 
 
 
 
 
 
 
                                                 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

Conclusions and recommendations 

The adoption of the Council Recommendation on Cancer Screening in 2003 is a prime example of the 
way in which agreement of joint priorities and principles of health policy at the Community level can 
stimulate  EU-wide  implementation  of  programmes  aiming  to  improve  the  health  of  the  European 
population.  

The positive experience with the Council Recommendation in encouraging successful implementation 
of complex population-based programmes reaching large segments of the European population should 
be taken into account in future efforts to improve the control of cancer and other chronic disease in 
the EU.  

Despite the broad consensus at the Community level and among the Member States in the expanded 
EU  on  the  importance  of  population-based  screening as  a  tool  of  cancer  control,  considerable  effort 
will  be  required  over  the  coming  years  to  successfully  implement  current  policies  and  to  overcome 
existing barriers to successful programme implementation. 

Even though the number of individuals currently attending cancer screening programmes in the EU is 
still  far  from  the  level  which  can  be  achieved  in  the  future,  the  expenditure  in  human  and  financial 
resources  is already  considerable. The scale of  these  resources  and  the  challenge  of  maintaining  an 
appropriate  balance  between  benefit  and  harm  of  screening  call  for  an  adequate  strategy  at  the 
Community  level  to  ensure  that appropriate  professional,  technical  and  scientific  support  is  available 
to Member States seeking to close the current gap between the status quo, and the potential of future 
expansion of evidence-based screening programmes to improve the health of the population.  

Adequate  provision  should  also  be  made  for  the  translational  phase  of  investigation,  planning, 
prioritising, and piloting prior to nationwide rollout of programmes or programme modifications, and 
for  research  on  innovative  screening  tests  and  on  the  impact  of  screening  in  the  population.  This 
particularly  holds  for  potentially  more  effective  methods  than  the  currently  recommended  test  for 
colorectal  cancer  screening  (FOBT)  and  for  new  methods  of  testing  and  complementary  preventive 
approaches  (such  as  HPV  vaccination  and  testing  for  primary  and  secondary  prevention  of  cervical 
cancer).  New  preventive  strategies  should  neither  be  recommended  for  routine  use  in  population-
based programmes nor in clinical practice until efficacy, benefits, and adverse effects, as well as cost-
effectiveness, have been adequately investigated. 

Increased  exchange  of  information  and  collaboration  between  Member  States,  and  professional, 
organisational  and  scientific  support  for  Member  States  seeking  to  establish  or  improve  population-
based screening programmes will also be required to successfully implement the Community strategy. 

Such assistance should be based on an appropriate technical and expert advisory capacity, as well as 
regular, systematic monitoring, evaluation and EU-wide status reporting on implementation of cancer 
screening programmes.  

Development and piloting of an EU-wide accreditation/certification scheme mandated by the Member 
States  and  based  on  EU  quality  assurance  guidelines  would  encourage  programmes  throughout  the 
EU to take the initiative to continuously improve performance and would help consumers to recognise 
which services achieve the EU standards. 

Given  the  current  need  for  professional,  organisational  and  scientific  support  for  Member  States 
seeking to implement or improve cancer screening programmes, adequate resources for appropriate 
Community actions are vital. 

6 

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1  Introduction 

After circulatory disease, cancer is the second largest cause of death in the European Union, account-
ing  for  two  out  of  ten  deaths  in  women  and  three  out  of  ten  deaths  in  men  in  2006  (Fig. 1 a). 
Substantial proportions of the cancer cases and deaths in the EU are attributable to breast, cervical or 
colorectal  cancer.  According  to  2006  estimates  of  the  International  Agency  for  Research  on  Cancer, 
331,000 cases and 90,000 deaths due to breast cancer, and 36,500 cases and 15,000 deaths due to 
cervical cancer were reported in women in the EU. New cases of colorectal cancer were reported in 
140,000 women and 170,000 men. Colorectal cancer deaths were registered for 68,000 women and 
78,000 men in the EU. Together, these cancers account for one out of two (47%) new cases and one 
out of three (32%) cancer deaths in women in the EU. In men, colorectal cancer currently accounts 
for one out of eight (13%) new cases and one out of nine (11%) cancer deaths (Fig. 1 b and c). The 
reported rates of these cancers vary widely across the EU, reflecting a major health burden in various 
Member  States.  The  burden  of  disease  is  particularly  unevenly  distributed  in  the  case  of  cervical 
cancer.  The  proportion  of  cases  and  deaths  attributed  to  this  cancer  is  markedly  elevated  in  all  but 
one of the Member States which acceded to the EU in 2004 and 2007 (Tables 1 and 2, Fig. 2 a - h).  

Regular, systematic examination of predominantly asymptomatic individuals of appropriate age using 
evidence-based  screening  tests  followed  by  appropriate  treatment  has  the  potential  to  significantly 
reduce the burden of breast, cervical and colorectal cancer in the population. This is accomplished by 
detecting and treating malignant tumours and precursor lesions earlier than would be the case with-
out  screening.  However,  this  benefit  may  only  be  achieved  if  quality  is  optimal  at  every  step  in  the 
screening  process.  Adequate  quality  assurance  requires  substantial  efforts,  due  to  the  complexity  of 
the  screening  process  which  extends  from  identification  and  invitation  of  the  target  population,  to 
performance  of  the  screening  test  and,  if  necessary,  diagnostic  work-up  and  treatment  of  screen-
detected lesions; and aftercare [14, 15, 19-20, 22, 33]. 

There  are  several  examples  of  effective  implementation  of  population-based  cancer  screening  pro-
grammes  in  the  European  Union.  Given  the  available  space,  they  cannot  all  be  mentioned  here.  A 
number  of  examples  are  provided  in  Annex  6  and  in  [18].  They  include  substantial  decreases  in 
cervical cancer mortality subsequent to introduction of population-based screening in Finland, and the 
United  Kingdom,  and  less  substantial,  but  pronounced  reductions  in  breast  cancer  mortality  after 
introduction of population-based screening in Sweden, Denmark, or The Netherlands. Similar benefits 
can  be  expected  in  other  Member  States  seeking  to  implement  or  improve  population-based  cancer 
screening programmes. 

Extensive knowledge and experience of screening has been acquired through the screening networks 
established  under  the  Europe  Against  Cancer  programme.8  The  European  screening  networks  have 
shown that a population-based approach provides the organisational framework essential to monitor-
ing and maintaining high quality at every step in the screening process. Nationwide implementation of 
population-based screening programmes makes services performing to the high standards accessible 
to the entire population eligible to attend screening. Large numbers of professionals undertake further 
specialisation  in  order  to  meet  the  screening  standards.  Consequently,  these  nationwide  efforts  also 
contribute  to  widespread  improvement in  diagnosis and  management  of  cancers  which  are  detected 
outside of screening programmes. 

The Health Ministers of the European Union have unanimously adopted a recommendation on cancer 
screening (Annex 2: Council Recommendation of 2 December 2003 on Cancer Screening [11]) based 
on the positive experience in the Europe Against Cancer programme and a number of its key achieve-

 8 The  “Europe  Against  Cancer”  programme”  consisted  in  six  successive  Community  action  plans  against  cancer 

adopted for the period 1987 to 2002. 

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ments, such as recommendations developed by the Advisory Committee on Cancer Prevention [1], the 
European Code Against Cancer [8], and the European Guidelines for Quality Assurance in Breast and 
Cervical Cancer Screening (for current editions see [14, 15]). The recommendation on cancer screen-
ing of the Council of the European Union acknowledges both the significance of the burden of cancer 
in the European population and the evidence for effectiveness of breast, cervical and colorectal cancer 
screening  in  reducing  the  burden  of  disease.  The  Council  Recommendation  spells  out  fundamental 
principles  of  best  practice  in  early  detection  of  cancer  and  invites  Member  States  to  take  common 
action  to  implement  national  cancer  screening  programmes  with  a  population-based  approach  and 
with  appropriate  quality  assurance  at  all  levels,  taking  into  account  European  Quality  Assurance 
Guidelines for Cancer Screening, where they exist. 

The  Council  Recommendation  recognises  that  the  cancer  burden  is  a  problem  of  international  char-
acter with important health implications and that cancer control requires coordination due to the com-
plexity and the scope of the involved activities and the time and effort required to successfully imple-
ment programmes extending over many years. The Member States are encouraged to find appropriate 
ways  of  implementing  cancer  screening  programmes  according  to  the  recommended  common 
principles, and with appropriate regard for the legal, regulatory, or self-regulatory environments in the 
individual Member states. Although the Council Recommendation is not legally binding for the Member 
States, it has widespread political support in the EU. This is reflected in a resolution adopted by the 
European  Parliament  in  June  2003  urging  the  Member  States  to  follow  similar  recommendations  for 
breast cancer screening [12]. The European Parliament reaffirmed this position in a nearly unanimous 
resolution in 2006 [13]. 

The Council Recommendation calls on the Member States to report to the European Commission on 
the implementation of the Recommendation within three years of its adoption and subsequently at the 
request of the Commission with a view to contributing to the follow-up of the Recommendation at the 
Community  level.  The  European  Commission,  in  turn,  is  invited  to  report  on  the  implementation  of 
cancer  screening  programmes  on  the  basis  of  the  information  provided  by  the  Member  States  not 
later than the end of the fourth year after adoption of the Recommendation, to consider the extent to 
which the proposed measures are working effectively, and to consider the need for further action. 

The present report has been prepared for the Commission services based on information provided by 
the Member States. The report is intended to provide initial feedback on programme implementation 
and  will  serve  as  the  basis  for  continued  efforts  to  expand  and  update  the  follow-up  of  the  Council 
Recommendation at the level of the European Union.  

2  Methodology 

Information on the implementation of cancer screening programmes in the Member States has been 
collected  in  a  written  survey  conducted  by  the  European  Commission  Directorate-General  for  Health 
and Consumers. A questionnaire in the official language of the respective Member State was sent to 
the EU permanent representations of each of the Member States in Brussels in May, 2007 (see below 
and  Annex  3).  Completed  questionnaires  were  returned  to  the  Commission  beginning  in  September 
2007  and  -  if  needed  -  translated  into  English.  After  translation,  the  raw  data  was  entered  into  a 
spreadsheet data base. Checks for internal consistency and completeness of the data were performed 
by  comparing  the  plausibility  of  data  supplied  for  interrelated  items  (i.e.  "personal  invitation"  and 
"population-based  screening")  and  by  comparison  with  data  collected  in  relevant  projects  in  the 
current  EU  Health  Programme  which  are  coordinated  by  the  International  Agency  for  Research  on 
Cancer  (IARC):  European  Cancer  Network  (ECN)  and  European  Network  for  Information  on  Cancer 

10 

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(EUNICE). Errors in data reporting or data entry which were detected by the plausibility checks were 
corrected; and, wherever possible, missing data was obtained from official sources in the respective 
Member States and from the above-mentioned projects based on reports of participating centres and 
programmes, official publications and statistics, and the scientific literature. The same procedure for 
collecting missing data was followed for those Member States from which filled in questionnaires were 
not received.  

Interim results of the present report were presented at two pan-European meetings which have taken 
place  in  the  framework  of  the  Slovenian  presidency  of  the  Council  of  the  European  Union.  At  the 
FACT9 conference held in February, 2008, in Brdo, Slovenia (The Burden of Cancer - How Can it be 
Reduced?)  health  experts  and  representatives  of  national  health  authorities  discussed  the  interim 
results  in  the  workshop  on  Cancer Screening.  Further  interim  results  were  reported  by  the  EU 
Commissioner  for  Health  Androulla  Vassiliou  at  the  informal  meeting  of  the  representatives  of  the 
national  health  authorities  of  the  EU  Member  States  which  was  held  in  Brdo,  in  April,  2008.  The 
Commissioner also requested that the Member States check the interim results and report corrections 
and relevant supplemental information which could be used to update the data base prior to public-
cation  of  the  present  first  report.  Up  to  May  2008  additional  information  was  received  from  several 
Member  States  through  their  respective  official  EU  representations.  Two  additional  Member  States 
also  provided  a  filled-in  questionnaire.  The  data  gathered  in  this  process  is  therefore  based  on  22 
filled in questionnaires received through the EU representations of the respective Member States and 
additional information provided by the health authorities of five Member States. 

2.1  Questionnaire  

The wording and the structure of the questionnaire corresponded closely to the format of the Council 
Recommendation.  The  questions  were  designed  to  acquire  information  on  the  national  situation. 
However, in some cases respondents provided regional data which was subsequently collated to the 
national  level.  Aggregate annual  data was  requested  for  items  which  can  be quantified,  such  as  the 
number  of  personal  invitations  issued  and  the  number  of  screening  examinations  performed  in  the 
most  recently  available  year.  Predefined  answer  categories  (yes;  no;  not  applicable/unknown)  were 
provided for most qualitative data such as information on adherence to specific items in the Council 
Recommendation.  Information  in  free  text  format  was  solicited  for  those  questions  which  were  not 
amenable to the predefined answer categories, for explanatory comments or for reporting on recent 
developments. 

The 36 questions in the questionnaire, some of which were subdivided in related items, were grouped 
in three sections (see below). 

Section I:  Role of cancer screening in national cancer control programmes 

Although  the  Council  Recommendation  does  not  specifically  refer  to  national  cancer  control 
programmes,  section  I  of  the  questionnaire  deals  with  this  subject  matter  (four  questions)  because 
incorporation  of  cancer  screening  into  national  cancer  control  programmes  may  have  a  decisive 
impact on the extent to which cancer screening programmes are implemented in a Member State.  

 9 FACT  (Fighting Against Cancer in Europe  Today):  a  project  co-financed  by  the  EU  Health  Programme  which 
supports the Slovenian EU presidency and which aims to ensure that best practice is shared across the EU and 
that existing gaps in cancer prevention, screening, treatment and care and research between and within Member 
States are reduced. http://www.projectfact.eu/about-the-project/ 

11

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Section II: Quantitative description of cancer screening in the Member States 

Section II of the questionnaire deals with quantitative information on cancer screening activities in the 
respective Member State (9 questions). The questions refer to the general approach for programme 
implementation recommended by the Council, i.e.: 

•  organised screening programmes 
•  with a population-based approach 

The  questions  also  refer  to  the  screening  tests  and  target  groups  specifically  recommended  by  the 
Council: 

•  mammography screening for breast cancer in women aged 50 to 69 
• 
•  Pap smear screening for cervical abnormalities from the ages of 20 to 30 (upper age limit not 

faecal occult blood screening for colorectal cancer in men and women aged 50 to 74 

specified) 
any other screening offered to persons of average risk 

• 

Aggregate data is requested for 2005 and, if available, 2006 on: 

•  The age groups eligible to attend organised screening programmes 
•  The number of persons invited 
•  The number of persons complying with respective invitations 
•  Public costs for organised screening programmes 
•  The number of persons offered screening without systematic invitation 
•  The number of screening tests provided to age-eligible persons outside of organised screening 

programmes and the respective public and private costs 

Section III:  Qualitative  information  on  the  fundamental  approach  to  implementation 

of screening programmes 

Section III of the questionnaire solicits qualitative information on the ways in which cancer screening 
activities are implemented in the various Member States (23 questions). The 34 items covered by the 
questions  in  this  section  correspond  closely  to  the  individual  recommendations  given  in  the  Council 
document  and  are  broken  down  into  6  parts.  Due  to  the  close  correspondence  with  the  Council 
document there is some overlap within and between elements in each part. 

Part 1:  Key aspects of implementation of cancer screening programmes 

The  items  in  part  1  deal  with  basic  principles  essential  to  delivery  of  high  quality  screening: 
Population-based approach 

Full information of participants about benefits and risks 

•  Adherence to EU quality assurance guidelines (for breast cancer screening)  
• 
•  Adequate comprehensive care for screen-positives 
•  Adequate human and financial resources for organization and quality control 
• 

Informed  programme  implementation  decisions  (based  on  disease  burden,  health  care 
resources, side-effects, cost effects, scientific trials and pilot projects) 

•  Call/recall system and effective diagnosis, treatment and aftercare 
•  Due regard to data protection 

Part 2:  Registration and management of screening data 

The items in part 2 refer to the infrastructure, methods and activities required to collect and manage 
the data essential to quality assurance of cancer screening programmes: 

•  Centralised data systems for running programmes 
•  Call/recall system to invite all targeted persons 
•  Data collection, management and evaluation for test performance, assessment and diagnosis 
•  Data handling in full accordance with data protection legislation 

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Part 3:  Monitoring of screening programmes 

The items in part 3 are related to part 2 and deal with the professional and technical efforts required 
to make adequate use of screening data for monitoring and quality assurance. 

•  Regular monitoring of process & outcome of organised screening by independent peer  review 

and with quick reports to public and staff 

•  Adherence to ENCR (European Network of Cancer Registries) screening data base standards & 

EU data protection laws 

•  Monitoring of programmes by national cancer registries at adequate intervals 

Part 4:  Training 

Only one item in the questionnaire (part 4) deals with the important requirement of adequate training 
for high quality screening. 

•  Personnel adequately trained at all levels to ensure delivery of high quality screening 

Part 5:   Compliance 

Part 5 deals with key issues of ethical and practical importance in information of the women targeted 
for screening. 

•  Priority for high compliance to organised screening based on fully informed consent 
•  Action  taken  to  assure  equal  access  to  screening,  accounting  for  special  socio-economic 

groups 

Part 6 

Introduction of novel screening tests taking into account international research 
results 

Part  6  points  out  key  steps  in  the  evidence-based  process  leading  up  to  governmental  decisions  on 
whether or not to implement or modify screening programmes. 

•  New screening tests only implemented after evaluation in RCTs 
•  Trials  run  on  any  of  the  following  subjects  (in addition  to screening-specific  parameters and 
mortality): treatment procedures, clinical outcomes, side effects, morbidity, quality of life 

•  Pooling of representative trials for assessment of level of evidence for new tests 
• 

Final decision on routine implementation of new screening tests only after conclusive results 
in RCTs and based on cost-effectiveness in respective health care system 
Introduction of test modifications in routine health care only after evaluation of effectiveness, 
possibly using epidemiologically validated surrogate endpoints 

• 

2.2  Responding Countries and Additional Data Sources 

Filled in questionnaires were obtained from 20 Member States by December 2007. After distribution of 
the interim results as described above, two additional questionnaires were received. The present re-
port is therefore based on information provided in the questionnaires returned by May 2008 from 22 
of the 27 Member States (81%)10: For the other five Member States, missing data was collected from 
official sources11 and from the ECN and EUNICE projects as described above. Although questionnaires 

10 Filled in questionnaires were received from: Austria, Belgium, Cyprus, Czech Republic, Estonia, France, Germany, 
Greece,  Hungary,  Italy,  Latvia,  Lithuania,  Luxembourg,  Malta,  Netherlands,  Poland,  Portugal,  Slovak  Republic, 
Slovenia, Spain, Sweden, United Kingdom. 

11 Additional  data  on  the  implementation  status  of  cancer  screening  programmes  was  provided  by  the  National 
Ministries  of  Health  in  Bulgaria  and  Denmark,  the  national  Mass  Screening  Registry  in  Finland,  the  National 

13

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were not received from all Member States, data provided by official sources was used to classify the 
screening  programme  status  in  all  27  Member  states  (100%)  based  on  the  definitions  used  in  the 
present report (see section 2.3). 

2.3  Definitions 

The  Council  of  the  European  Union  recommends  implementation  of  cancer  screening  programmes 
with  an  organised,  population-based  approach,  with  quality  assurance  at  all  appropriate  levels.  The 
Council Recommendation describes those elements which are considered essential to fulfil this global 
standard,  but  it  does  not  provide  definitions  of  terminology  which  could  be  used  to  compare 
differences between Member States in the degree to which screening programmes are implemented. 
In order to focus on the specific elements in the Council Recommendation, the survey questionnaire 
did not introduce definitions. However, for internal consistency and in order to permit comparison with 
other reports, the results in the present report are presented using a common terminology based on 
the uniform definitions described in section 2.3.1 and the respective subsections. 

2.3.1  Screening programmes 

Perceptions  of  what  constitutes  a  screening  programme  vary  widely.  The  responses  to  the  present 
survey  and  experience  in  the  ECN  and  EUNICE  projects  reflect  the  wide  consensus  that  a  minimum 
degree of public responsibility, organisation and supervision is required for screening activities to be 
understood as taking place in the context of a programme as opposed to non-programme screening. 
However, substantially more organisational elements are commonly regarded as essential in order to 
refer to screening activities as taking place in an "organised" programme. In practice, differentiation 
between  "organised"  and  "unorganised"  screening  programmes  is,  to  a  certain  extent,  arbitrary  and 
does  not  take  into  account  the  continuous  gradient  extending  from  poorly  organised  to  highly 
organised programmes. The terminology used in the present report reflects the above considerations.  

2.3.1.1  "Programme" vs. "non-programme" screening 

In many health care systems, prophylactic examination of apparently healthy individuals for the pur-
pose  of  early  detection  and  treatment  of  cancer  may  take  place  both  in  the  framework  of  publicly 
mandated  screening  programmes  as  well  as  outside  of  any  such  programme.  To  qualify  as  a  pro-
gramme there should be a public screening policy documented in a law, or an official regulation, de-
cision, directive or recommendation. The policy should define, as a minimum, the screening test, the 
examination intervals and the group of persons eligible to be screened; and the screening examina-
tions should be financed by public sources (apart from a possible co-payment). 

In numerous countries, an appreciable amount of non-programme examinations for early detection of 
cancer  may  also  be  performed  in  a  diagnostic  or  clinical  context  (commonly  referred  to  as  "grey," 
“wild,”  or  “opportunistic”  screening).  Such  examinations  may or  may  not  be performed  according  to 
the public screening policy, if one exists. For example, some apparently healthy women receiving non-
programme mammography in a clinical setting may be older or younger than the recommended age 
for  mammography  screening.  Also,  their  mammographic  examinations  may  or  may  not  be  publically 
financed, depending on the rules for reimbursement and/or payment of diagnostic mammography in 
the respective Member State. It is generally not possible to distinguish "grey" screening examinations 
from solely diagnostic examinations in official statistics. For the purposes of the present report, "grey" 

Screening Programme in Ireland, and the national Ministry of Public Health and the National Management Unit for 
Screening Programmes in Romania. 

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screening  examinations  are  not  considered  to  entail  screening  performed  in  the  context  of  a  pro-
gramme. 

2.3.1.2  Organised screening  

"Organised"  programmes  for  delivery  of  screening  services  generally  require  a  higher  degree  of 
programme management than the minimum expected to distinguish between "programme screening" 
as opposed to "non-programme screening". In an "organised" programme, in addition to the targeted 
population group(s), the screening test and the screening interval(s), the programme policy generally 
also specifies other procedures and provides for a team at the national or regional level which is re-
sponsible  for  implementing  the  policy,  i.e.,  for  coordinating  the  delivery  of  the  screening  services, 
maintaining requisite quality, and reporting on performance and results. Such elements generally pro-
vide for supervision and monitoring of most steps in the screening process, as well as comprehensive 
guidelines and rules defining standard operating procedures. In addition, a quality assurance structure 
is required and a means of ascertaining the population burden of the disease should be available [14, 
15, 19, 20]. 

2.3.1.3  Population-based screening 

Population-based screening means that in each round of screening the persons in the eligible target 
population  in  the  area  served  by  a  programme  are  individually  identified  and  personally  invited  to 
attend  screening.  Population-based  screening  programmes  generally  require  a  high  degree  of 
organisation in order to assure that the invitational activities are performed reliably and effectively and 
are adequately coordinated with the subsequent steps in the screening process.12 

2.3.2  Country implementation status 

The present report differentiates between Member States in which cancer screening programmes are 
lacking and those in which programmes have been or are currently being implemented. Note that in 
those Member States in which cancer screening programmes are lacking, substantial volumes of non-
programme screening  may  be  occurring.  Member  States with  cancer  screening programmes may  be 
further  differentiated  as  to  whether  the  screening  programmes  are  population-based  or  non-
population-based.  Furthermore,  public  policy  may  aim  to  implement  screening  nationwide  or  only  in 
certain regions. Finally, in the case of population-based screening, nationwide or regional programme 
implementation  may  be  in  various  stages  of  development:  planning  phase,  pilot  phase,  rollout 
ongoing, or rollout complete (i.e. programme is fully established). For rollout to be complete at least 
ca. 90% of the eligible target population in the respective region or country should have received at 
least  one  personal  invitation  to  attend  the  screening  programme,  and  all  elements  of  the  screening 
services  should  be  fully  functional  in  order  to  assure  that  every  eligible  person  has  an  equal 
opportunity to participate in screening. In some cases, implementation status may be mixed because 
the  country  is  in  a  phase  of  transition  from  one  type  of  programme  to  another  (i.e.,  from  non-
population-based  to  population-based  programmes)  or  because  both  types  of  programmes  exist  in 
various  regions.  When  data  on  the  volume  of  invitations  was  not  available  which  confirmed  the 
plausibility of programmes considered to be completely rolled out by data providers, confirmation that 
the volume criteria were fulfilled was sought from official or authoritative sources. 

12 Particularly  in  cervical  cancer  screening  programmes  with  intervals  of  three  or  more  years,  some  population-

based programmes only individually invite non-attenders.  

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3  Quantitative  description  of  screening  implementation  in  the 

EU Member States 

The  most  recently  available  quantitative  data  on  implementation  of  breast,  cervical  and  colorectal 
cancer screening programmes in the EU is presented in Figs. 3 - 7 and Tables 3 - 5. To indicate the 
extent to which screening programmes have been or currently are being established, the numbers of 
persons  and  the  respective  proportions  of  the  EU  population  targeted  for  screening  are  shown  for 
relevant age ranges of women and men in the individual Member States and in the EU as a whole. For 
breast cancer screening using mammography and colorectal cancer screening using the faecal occult 
blood  test,  proportions  of  the  target  populations  in  the  EU  are  calculated  based  on  the  age  ranges 
specified  in  the  Council  Recommendation  (50-69-year-old  women,  and  50-74-year-old  women  and 
men,  respectively).  For  cervical  cancer  screening,  the  proportions  are  calculated  based  on  the  age 
range  which  corresponds  to  the  minimum  target  age  range  recommended  in  the  recently  updated, 
second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening (30-60 
years,  [15]).  Data  is  broken  down  by  the  type  of  screening  programme  (population-based  or  non-
population-based);  whether  or  not  government  policy  aims  for  nationwide,  or  merely  regional 
implementation;  and,  in  the  case  of  population-based  screening  programmes,  the  current  phase  of 
implementation (in decreasing degree of implementation: complete rollout across a country or region, 
rollout ongoing, piloting, or planning). For programme definitions see section 2.3.  

Due to the national and regional variation in the definition of populations targeted for screening, the 
dimensions of the screening programmes shown in Tables 3 a – 5 a underestimate somewhat the full 
volume of screening activities in the EU. Tables 3 b – 5 b therefore present estimates of the full target 
populations in the various Member States in an entire round of screening, i.e., without adjustment for 
the duration of a screening round. Furthermore, the number of screening examinations currently per-
formed in a 12-month period is indicated as far as possible based on available data. The programme 
type  and  country  implementation  status  reported  in  Figs.  3  -  5  and  Tables  3 a  –  5 a  refer  to  the 
situation in 2007; the respective target population sizes are unadjusted estimates based on the most 
recently  available  data,  in  most  cases  EUROSTAT13  data  for  1  January  2007  is  used.  The  annual 
volume of invitations and examinations presented in Tables 3 b - 5 b refer to the most recent calendar 
year for which data is currently available, in most cases 2006.  

3.1  Breast cancer screening 

3.1.1  Policy consensus 

There is substantial consensus between the Member States and the Council of the European Union in 
promoting  breast  cancer  screening  based  on  mammography  as  a  public  health  policy.  Programmes 
were running or being established in at least 26 of the 27 Member States in 2007. Population-based 
programmes were running or being established in 22 Member States (Austria, Belgium, Cyprus, Czech 
Republic,  Denmark,  Estonia,  Finland,  France,  Germany,  Hungary,  Ireland,  Italy,  Luxembourg,  Malta, 
Netherlands,  Poland,  Portugal,  Romania,  Slovenia,  Spain,  Sweden,  and  the  United  Kingdom).  Of  the 
five  Member  States  operating  non-population-based  breast  screening  programmes  based  on 
mammography  in  2007  (Austria,  Greece,  Latvia,  Lithuania,  and  the  Slovak  Republic),  one  was  also 
piloting  or  planning  implementation  of  a  nationwide  population-based  programme  (Austria;  Fig.  3  a, 
Table 3 a).  

13 EUROSTAT: Statistical Office of the European Communities 

16 

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3.1.2  Number of persons affected by screening 

Large numbers of women are affected by the breast cancer screening policies now being implemented 
in  the  EU.  Nearly  59  million  women  in  the  EU  are  of  the  target  age  for  breast  cancer  screening 
specified  in  the  Council  Recommendation  (50-69  years).  Nine  out  of  10  women  in  this  age  range  in 
the EU (91 %, 54 million) were targeted for breast cancer screening in 2007 in the 22 Member States 
which  had  adopted  policies  aiming  for  implementation  of  population-based  screening  programmes. 
Less  than  one  in  10  women  in  this  age  group  in  the  EU  (6%,  3.7  million)  was  targeted  for  breast 
cancer  screening  in  the  five  Member  States  which  were  running  non-population-based  screening 
programmes.14 If women outside the 50-69-year-old age range are also taken into account, over 64 
million  women  were  targeted  by  breast  cancer  screening  programmes  which  were  running  or  being 
established in the EU in 2007 (Fig. 3 a – c, Table 3 a and b). 

3.1.3  Programme implementation status 

A large proportion of the 50-69-year-old women targeted for breast cancer screening in the EU resides 
in Member States which were still in the process of expanding or establishing population-based breast 
screening programmes in 2007. Four out of 10 women in this age group in the EU (41%) were tar-
geted for breast cancer screening in the 11 Member States in which nationwide rollout of population-
based  programmes  is  complete    (Belgium,  Cyprus,  Estonia,  Finland,  France,  Hungary,  Luxembourg, 
The Netherlands, Spain, Sweden, and the United Kingdom). A slightly higher proportion of the women 
in this age group in the EU (44.0%) was targeted for breast cancer screening in the seven Member 
States  in  which  nationwide  rollout  of  population-based  programmes  was  ongoing  (Czech  Republic, 
Denmark,  Germany,  Ireland,  Italy,  Poland,  and  Portugal).  Under  one  out  of  10  women  in  this  age 
group  in  the  EU  (7%)15  was  targeted  by  the  nationwide  population-based  breast  screening  pro-
grammes being piloted (Austria, 2%) or planned (Malta, Romania and Slovenia, 5%) in four Member 
States in 2007 (Fig. 3 a - c, Table 3 a).  

3.1.4  Variation between Member States 

Despite the broad consensus among the Member States on the current priority of establishing breast 
cancer screening programmes, the way screening programmes are implemented varies across the EU. 
The greatest uniformity is reflected in the screening interval which only exceeded a two-year period 
for  women  in  the  age  group  50-69  years  in  two  of  the  26  Member  States  running  or  establishing 
breast  screening  programmes  based  on  mammography  in  2007  (Malta  and  the  United  Kingdom,  3 
years).  Twelve  Member  States  had  adopted  the  target  age  range  specified  in  the  Council 
Recommendation (50-69 years). Seven Member States did not target the full 50-69-year age range in 
all regions served by breast screening programmes (Estonia, Hungary, Ireland and Malta) or in some 
regions (Finland, Spain and the United Kingdom).16,17 The proportion of the female population in the 
EU in the age group 50-69 years which was not targeted for breast screening in the aforementioned 

14 Note that two Member States in which non-population-based breast screening programmes were running in 2007, 

were also piloting or planning nationwide population-based programmes (Austria and Slovenia, respectively). 

  The population-based breast screening programme in Slovenia began nationwide rollout in April, 2008. 
  National cancer control and action plans under development in Greece and Latvia in 2008 also foresee transitions 

to population-based breast cancer screening. Adoption of the plans in Latvia is foreseen in October, 2008. 

  Breast cancer screening will also be dealt with in the National Cancer Control Programme under development in 

Bulgaria. 

15 Proportions are rounded. 
16 In 2007 Finland began rolling out extension of the target age group to cover the entire 50-69-year age range in 

all regions of the country. 

17 The UK breast screening programmes target women 50-70 years of age (except in Northern Ireland which targets 

women 50-64 years). In all UK programmes older women can request 3-yearly invitation to screening. 

17

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Member States is 2% (Table 3 a). Women below 50 years of age were targeted by eight, and women 
above 69 years of age were targeted by the same number of Member States running or establishing 
breast screening programmes in 2007. The narrowest age range targeted for population-based breast 
cancer screening was 50-59 years, which was practiced nationwide in Estonia and in some regions of 
Finland and has been adopted for the initial phase of the population-based programme being planned 
in Malta.18 The broadest age range targeted for population-based breast screening was 40-74 years, 
which was practiced in several regions in Sweden in 2007 (Tab. 3 b).19 

3.1.5  Volume of programme screening 

The  data  available  for  the  present  report  provides  an  incomplete  picture  of  the  current  volume  of 
breast  screening  programmes  in  the  EU.  The  total  numbers  of  women  personally  invited  to,  and 
attending  screening  programmes  in  a  one-year  period  shown  in  Table  3 b  (14  and  9  million, 
respectively) neither include women from the regionally organized, nationwide, population-based pro-
gramme in Sweden. Nor do they include invitations to the population-based programmes in the Czech 
Republic and Poland. As for most Member States, the reference year for invitations and examinations 
for the Czech Republic and Poland is 2006, the year before transition from a non-population-based to 
a population-based programme with personal invitation started in these Member States. Therefore no 
invitations  are  entered  in  the  table  for  these  Member  States.  The  same  applies  to  the  population-
based  programmes  in  the  planning  phase  in  Malta,  Romania  and  Slovenia  in  2007.  The  numbers  of 
screening participants from the non-population-based programmes in Austria, Greece, Latvia and the 
Slovak Republic are also not currently available. Furthermore, the total volume of screening is increas-
ing  rapidly  in  the  group  of  Member  States  in  which  nationwide  rollout  of  screening  programmes  is 
ongoing; and the overall target population in these Member States is significant (27 million women). If 
these  factors  are  taken  into  account,  a  conservative  estimate  would  yield  approximately  21  million 
women  invited  to,  and  approximately  12  million  women  attending  breast  cancer  screening  pro-
grammes in the EU in 2007. 

3.1.6  Volume of non-programme screening 

The  volume  of  mammography  examinations  performed  outside  of  publicly  mandated  screening  pro-
grammes  has  been  reported  for  only  8  of  the  27  EU  Member  States  (2.8  million  examinations 
annually).  The  available  data  is  insufficient  to  estimate  the  actual  volume  of  non-programme 
examinations  in  the  EU  in  2007,  although  the  number  of  examinations  is  likely  to  be  substantially 
higher. 

3.2  Cervical cancer screening 

3.2.1  Policy consensus 

Cytology-based cervical cancer screening is also widely accepted as a public health policy in the EU. 
Programmes  according  to  the  definitions  used  in  the  present  report  (see  section  2.3)  are  currently 
running  or  being  established  in  25  of  the  27  Member  states.  Compared  to  the  situation  with  breast 
cancer screening, programme implementation varies more markedly and there is substantial deviation 
from the population-based approach recommended by the Council of the European Union. Population- 

18 See previous footnote on Finland. 
19 Until 2007 the breast screening guidelines of the Swedish National Board of Health and Welfare accepted regional 
variation in the targeted age range for breast cancer screening; the current national guidelines recommend the 
full 40-74-year age range without exception. 

18 

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based  programmes  are  currently  running  or  being  established  in  15  Member  States  (Denmark, 
Estonia,  Finland,  France,  Hungary,  Ireland,  Italy,  Netherlands,  Poland,  Portugal,  Romania,  Slovenia, 
Spain, Sweden, and the United Kingdom).20 Non-population-based screening programmes as defined 
in  section  2.3  are  running  in  12  Member  States  (Austria,  Belgium,  Bulgaria,  Czech  Republic,  France, 
Germany,  Greece,  Latvia,  Lithuania,  Luxembourg,  Slovak  Republic,  and  Spain),  in  two  of  which 
regional  population-based  programmes  are  also  currently  piloted  or  established  (France  and  Spain, 
respectively; Fig. 4 a and b, Table 4 a).  

3.2.2  Number of persons affected by screening 

Significantly  larger  numbers  of  women  are  affected  by  the  cervical  cancer  screening  policies  now 
being  implemented  in  the  EU  than  is  the  case  with  breast  cancer  screening,  due  to  the  extended 
target age range of cervical cancer screening programmes. Nearly 109 million women in the EU are in 
the age group 30-60 years which corresponds to the minimum age group for cervical cancer screening 
specified in the currently updated second edition of the European Guidelines for Quality Assurance of 
Cervical Cancer Screening [15].21 Five out of 10 women in this age group in the EU (51 %, 55 million) 
are  targeted  for  cervical  cancer  screening  by  the  15  Member  States  which  have  adopted  policies 
aiming for implementation of population-based screening programmes. Nearly five out of 10 women in 
this  age  group  in  the  EU  (47%,  51 million)  are  targeted  for  cervical  cancer  screening  in  the  12 
Member  States  which  have  adopted  policies  aiming  for  implementation  of  non-population-based 
screening programmes. If women outside the 30-60-year-old age range are also taken into account, 
146 million women are targeted by cervical cancer screening programmes which are currently running 
or being established in the EU (Fig. 4 a – c, Table 4 a and b). 

3.2.3  Programme implementation status 

The majority of the 30-60-year-old female population in the EU resides in Member States which have 
already established cervical cancer screening programmes nationwide. Two out of 10 women aged 30-
60  years  in  the  EU  (22%)  are  targeted  for  cervical  cancer  screening  in  seven  Member  States  which 
have rolled out population-based programmes nationwide (Denmark, Finland, Hungary, Netherlands, 
Slovenia,  Sweden  and  the  United  Kingdom).  A  higher  proportion  of  the  women  in  this  age  group  in 
the  EU  (41%)  is  targeted  for  cervical  cancer  screening  by  the  non-population-based  programmes 
established nationwide in 11 other Member states (Austria, Belgium, Bulgaria, Czech Republic, France, 
Germany,  Greece,  Latvia,  Lithuania,  Luxembourg,  and  the  Slovak  Republic).  Nearly  three  out  of  10 
women  in  this  age  group  in  the  EU  (27%)  is  targeted  by  the  nationwide  population-based  cervical 
screening  programmes  currently  being  planned  (Ireland  and  Portugal,  3%),  piloted  and  planned 
(Romania, 4%), or rolled out (Italy and Poland, 20%) in five Member States. Somewhat less than one 
in  ten  women  in  this  age  group  in  the  EU  (8%)  is  targeted  by  regional  cervical  cancer  screening 
programmes  in  five  Member  States,  with  a  non-population-based  approach  in  the  established 
programmes  in  Spain  (7%)  and  a  population-based  approach  in  the  established  programmes  in 
Ireland  and  Spain  (<1%),  in  the  programme  being  rolled  out  in  Portugal  (<1%),  and  in  the  pilot 
programmes in France(<1%; Fig. 4 a – c, Table 4 a). 

20  In Cyprus an Ad hoc committee is planning a nationwide population-based cervical cancer screening programme 

for women 30-60 years of age based on cytology. 

21  The current second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening recom-

mends 30-60 years or 30-65 years as the minimum age group to target for cervical cancer screening.  

19

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3.2.4  Variation between Member States 

The wider variation between the Member States in the way cervical cancer screening is implemented 
is also evident in programme policies on the duration of the screening interval and the age of women 
targeted  for  screening  (Table  4  b).  A  one-year  interval  between  two  negative  screening  tests  is  the 
current  policy  in  six  member  states  with  cervical  screening  programmes  (Austria,  Czech  Republic, 
Germany, Greece, Luxembourg and the Slovak Republic). A two-year screening interval is adopted in 
one Member State (Bulgaria), and a three-year interval is currently adopted in 14 Member States, nine 
of  which  apply  this  interval  to  the  entire  target  age  group  (Belgium,  France,  Hungary,  Italy,  Latvia, 
Lithuania,  Poland,  Portugal  and  Slovenia)  and  five  of  which  also  apply  a  five-year  interval  to 
subgroups  of  participants,  depending  on  age  and/or  the  screening  region  (Denmark,  Ireland,  Spain, 
Sweden and the United Kingdom). A five-year interval is applied to the entire target population in four 
Member States (Estonia, Finland, Netherlands and Romania).  

In all but one of the 25 Member States currently running or establishing cervical cancer screening pro-
grammes,  the  target  age  group  includes  at  least  the  age  range  30  to  59  years.22  The  lowest  age 
targeted by most  screening programmes is 30 years in 5 Member States (Estonia, Finland, Lithuania, 
the Netherlands, and Spain), 25 years in 10 (Belgium, the Czech Republic, France, Hungary, Ireland, 
Italy, Poland, Portugal, Romania, and the United Kingdom), 23 years in two (Denmark and Sweden), 
20  years  in  four  (Germany,  Greece,  Latvia  and  Slovenia)  and  less  than  20  years  in  three  Member 
States (Austria, Luxembourg and the Slovak Republic). The highest age targeted by most programmes 
for cervical cancer screening is 59 or 60 years in nine (Denmark, Estonia , Finland, Ireland, Lithuania, 
The  Netherlands,  Poland,  Spain,  and  Sweden),  64  or  65  years  in  nine  (Belgium,  Bulgaria,  France, 
Hungary,  Italy,  Portugal,  Romania,  Slovenia  and  the  United  Kingdom),  and  69  or  70  years  in  two 
Member States (the Czech Republic and Latvia). There is no upper age limit on the target population 
in five Member States (Austria, Germany, Greece, Luxembourg and the Slovak Republic; Table 4 b).  

3.2.5  Volume of programme screening 

Table  4 b  shows  the  number  of  women  invited  to,  and  attending  cervical  cancer  screening  pro-
grammes  in  the  EU  in  a  one-year  period  based  on  data  for  10  and  19  Member  states,  respectively. 
The totals in the table (9.3 million invited and 28.6 million screened) do not include women invited to 
the  population-based  screening  programmes  established  nationwide  in  Denmark  and  Sweden;  the 
pilot  population-based  programmes  in  France  and  Romania,  one  of  the  regional  population-based 
screening  programmes  in  the  United  Kingdom  (Scotland),  and  the  regional  population-based  pro-
grammes in Spain. As for most Member States, the reference year for the data from Poland is 2006, 
the year before transition to a population-based programme with personal invitation in that Member 
State.  Therefore  no  invitations  are  entered  in  the  table  for  Poland.  Data  on  the  number  of  women 
attending  screening  is  lacking  from  the  population-based  nationwide  and  pilot  programmes  in 
Denmark and France, respectively, as well as from the non-population-based programmes in Austria, 
Greece,  the  Slovak  Republic  and  most  regions  in  Spain.  If  these  factors  are  taken  into  account,  a 
conservative  estimate  would  yield  over  17  million  women  invited  to,  and  approximately  32  million 
women attending cervical screening programmes in the EU in 2007. 

3.2.6  Volume of non-programme screening 

The volume of cervical cancer screening examinations performed outside of publicly mandated screen-
ing programmes has been reported for 10 of the 27 EU Member States (over 9 million examinations 
annually).  The  available  data  is  insufficient  to  estimate  the  actual  volume  of  non-programme 
examinations in the EU, although the number of examinations is likely to be substantially higher. 

22  Note regional variation in the targeted age ranges in some member states: the targeted age ranges indicated in 
the text for Denmark, France, Finland, Spain and the United Kingdom, in particular, apply to most, but not all 
regions. The youngest age targeted for cervical cancer screening in Bulgaria is 31 years. 

20 

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3.3  Colorectal cancer screening 

3.3.1  Policy consensus 

Colorectal  cancer  screening  is also  widely  accepted as  a  public  health  policy  in  the EU.  Programmes 
are  currently  running  or  being  established  in  19  of  the  27  Member  States.  Twelve  of  the  Member 
States have adopted the population-based approach to programme implementation recommended by 
the  Council  of  the  European  Union  (Cyprus,  Finland,  France,  Hungary,  Italy,  Poland,  Portugal, 
Romania, Slovenia, Spain, Sweden and the United Kingdom).23 Seven Member States have established 
non-population-based  programmes  (Austria,  Bulgaria,  the  Czech  Republic,  Germany,  Greece,  Latvia, 
and  the  Slovak  Republic).  Compared  to  the  situation  with  breast  and  cervical  cancer  screening  in 
2007, colorectal cancer screening programmes were running or being established in a smaller number 
of the Member States, programme implementation was less advanced, and a smaller proportion of the 
population specified in the Council Recommendation was targeted (Figs. 5 - 7, Table 5 a). 

3.3.1.1  Recommended screening method (FOBT) 

The screening test for colorectal cancer specified in the Council Recommendation is the faecal occult 
blood  test  (FOBT),  a  non-invasive  test  taken  at  home  by  the  screening  participant  and  generally 
returned  by  surface  mail  to  a  laboratory  for  processing.24  Fig.  5  shows  the  implementation  status  of 
the  18  Member  States  which  have  adopted  the  FOBT  for  use  in  colorectal  cancer  screening  pro-
grammes.  

3.3.1.2  Novel screening tests still under evaluation (Endoscopy) 

Novel screening tests still under evaluation have been adopted in a limited number of Member States 
currently running or establishing colorectal cancer screening programmes. The novel screening tests 
consist  in  colonoscopy or  flexible  sigmoidoscopy,  i.e.,  invasive,  endoscopic procedures  performed  by 
medical personnel. The screening programme in one Member State (Poland) uses only colonoscopy as 
the screening test. Screening programmes currently running or being established in six other Member 
States  (Austria,  Cyprus,  Germany,  Greece,  Italy  and  the  Slovak  Republic)  employ  endoscopic 
screening  tests  (either  flexible  sigmoidoscopy  or  colonoscopy)  as  a  supplement  or  an  alternative  to 
FOBT (see Fig. 6 and section 3.3.4).25 

3.3.2  Number of persons affected by screening 

Despite the less widespread implementation of colorectal cancer screening programmes compared to 
breast and cervical cancer screening, very large numbers of individuals are affected by the colorectal 
cancer screening policies adopted in the EU because both sexes are targeted. In 2007 approximately 
136 million women and men in the EU were in the target age group for colorectal cancer screening 
specified in the Council Recommendation (50-74 years). Over four out of 10 women and men (43 %, 
58 million) in this age group in the EU were targeted for colorectal cancer screening in the 12 Member 
States  which  have  adopted  policies  aiming  for  implementation  of  population-based  programmes. 
Approximately three out of 10 women and men (27%, N=37 million) in this age group in the EU were 

23 In Denmark, the results of an FOBT-based pilot study in 2005-2006 and international findings are being analyzed 
in a health technology assessment. Based on the HTA the National Board of Health will make a recommendation 
expected in June 2008 concerning nationwide colorectal screening programme. 

  In The Netherlands, three pilot studies dealing with FOBT (Amsterdam and Nijmegen), FOBT and FS (Rotterdam) 
and CS (Maastricht) involving a total of over 30,000 subjects were running in 2007. Results will provide evidence 
for policy decision on nationwide implementation of screening. 

24 Faecal occult blood tests are designed to detect blood in stool specimens which is not visible to the human eye. 
25 Endoscopic colorectal screening examinations visualize the inside of the colon (large intestine and rectum) using 
flexible  optical  instruments.  Full  colonoscopy  permits  examination  of  the  entire  colon.  Flexible  sigmoidoscopy 
permits examination of the rectum and the sigmoid colon. 

21

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targeted  for  colorectal  cancer  screening  in  the  seven  Member  States  which  have  adopted  policies 
aiming for implementation of non-population-based programmes. If women and men outside the age 
range 50-74 years are also taken into account, approximately 106 million individuals were targeted for 
colorectal cancer screening in the EU in 2007 (Fig. 7 a and b, Table 5 a and b). 

3.3.3  Programme implementation status 

A  majority  of  the  50-74-year-old  female  and  male  population  in  the  EU  resides  in  Member  States 
which  have  already  established  or  are  still  in  the  process  of  rolling  out  colorectal  cancer  screening 
programmes nationwide. More than three out of 10 women and men (34%) in this age group in the 
EU was targeted for colorectal cancer screening by the population-based programmes currently being 
rolled out nationwide by five Member States (Finland, France, Italy, Poland and the United Kingdom). 
Approximately three out of 10 women and men (27%) in this age group in the EU were targeted for 
colorectal  cancer  screening  by  the  non-population-based  programmes  established  nationwide  by 
seven Member  states  (Austria,  Bulgaria,  Czech Republic,  Germany,  Greece,  Latvia,  Slovak Republic). 
Approximately one out of 10 women and men in this age group in the EU (9%) was targeted by the 
nationwide  population-based  colorectal  cancer  screening  programmes  which  were  being  piloted 
(Hungary, 2%) or planned (Cyprus, Portugal, Romania, Slovenia; 6%) by five Member States in 2007. 
A very small proportion of the 50-74-year-old female and male population in the EU (<1%) is targeted 
by regional population-based programmes being planned in Sweden and piloted in Spain (Figs. 5 – 7, 
Table 5 a and b).26  

3.3.4  Variation between Member States 

Variation between the Member States in the way colorectal cancer screening is implemented is more 
pronounced  than  is  the  case  with  breast  or  cervical cancer  screening.  Out  of the  19  Member  States 
running or establishing colorectal cancer screening programmes in 2007, 12 (Bulgaria, Czech Republic, 
Finland,  France,  Hungary,  Latvia,  Portugal,  Romania,  Slovenia,  Spain,  Sweden,  and  the  United 
Kingdom) have adopted only the non-invasive test specified in the Council Recommendation (FOBT), 
six (Austria, Cyprus, Germany, Greece, Italy, Slovak Republic) use both the FOBT and an endoscopic 
test  for  primary  screening,  and  one  (Poland)  uses  only  an  endoscopic  test  (colonoscopy).  With  the 
exception of Italy, in which flexible sigmoidoscopy is the endoscopic screening test used in seven loco-
regional  programmes  in  2007,  the  other  Member  States  with  endoscopic  programmes  have  adopted 
colonoscopy as the primary screening test. In two Member states (Germany and Italy) the FOBT is not 
provided for persons electing to undergo endoscopic screening; in Austria and Greece, screenees may 
attend  endoscopic  and  FOBT  screening  during  the  same  screening  round.  The  two  FOBT  and  endo-
scopic screening rounds are separate in Cyprus. It is not clear from the available information whether 
the tests will be mutually exclusive in the programme planned for the Slovak Republic.  

Out of 17 Member States for which information on the FOBT screening interval is available, 11 have 
adopted  a  2-year  interval  for  all  participants  with  a  negative  test  result.  In  two  Member  States 
(Austria,  and  Germany)  a  1-year  interval  applies  in  some  cases.  Two  Member  States  (Bulgaria  and 
Latvia) have adopted a 1-year interval. One Member State has adopted a 5-year interval (Greece) and 
another Member State (Cyprus) plans invitation once in a lifetime to FOBT screening, five years prior 
to  invitation  once  in  a  lifetime  to  colonoscopic  screening.  In  the  Italian  endoscopic  screening 
programmes invitations to flexible sigmoidoscopy are also issued once in a lifetime. The recommended 
interval  for  colonoscopy  is  5  years  in  Greece  and  10  years  in  the  four  Member  States  which  have 
adopted  endoscopic  screening  programmes.  Due  to  the  upper  age  limits  of  the  respective  target 

26 The population-based colorectal cancer screening programme in the Stockholm County was in the planning phase 

in 2007 and became operational in January, 2008. 

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populations,  the  number  of  screening  colonoscopies  is  limited  to  once  or  twice  in  a  lifetime  in 
Germany and Poland.  

The full age range recommended by the Council of the European Union for colorectal cancer screening 
using the FOBT (50-74 years) was only targeted in 9 Member States in 2007 (Austria, Bulgaria, Czech 
Republic,  France,  Germany,  Greece,  Latvia,  Romania  and  the  Slovak  Republic).  Nine  Member  States 
target  less  than  the  full  age  range  for  FOBT  screening  (Cyprus,  Finland,  Hungary,  Italy,  Portugal, 
Slovenia, Spain, Sweden, and the United Kingdom).27 Only two Member States (France and Romania) 
have adopted a target age range which corresponds exactly to the age range specified in the Council 
Recommendation.  The  shortest  age  range  targeted  for  FOBT  screening  is  in  Cyprus,  which  plans  to 
invite 50-year-old women and men once-in-a lifetime to FOBT screening, followed five years later by 
once-in-a-lifetime colonoscopy screening. The youngest age targeted for FOBT screening in the EU in 
2007 was 31 years in one Member State (Bulgaria) and 50 years in 16 Member States. Programmes 
running or being established in only three Member States begin targeting women and men of higher 
age (Finland, Sweden and the UK) .28  

In  2007  the  target  ages  for  endoscopic  colorectal  cancer  screening  in  average  risk  persons  ranged 
from  the  one-year  age  groups  in  the  two  Member  States  with  once-in-a-lifetime  screening 
programmes (55 years in Cyprus and 58 or 60 years in Italy), to age ranges of 15 years or more in 
the other four Member States with a ten-year screening interval (50-65 years in Poland, 55-74 years 
in  Germany,  50  or  more  years  in  Austria  and  the  Slovak  Republic)  and  the  single  Member  State 
(Greece) with a 5-year interval (50 years and older). 

The proportion of the female and male population in the EU in the age group 50-74 years which was 
not  targeted  for  colorectal  cancer  screening  in  the  Member  States  running  or  establishing  colorectal 
cancer screening programmes was 22% in 2007.  

3.3.5  Volume of programme screening 

Table 5 b shows the number of women and men personally invited to, and attending colorectal cancer 
screening  programmes  in  the  EU  in  a  one-year  period  based  on  data  for  7  and  9  Member  states, 
respectively.  Five  member  states  with  population-based  programmes  in  the  planning  phase  had  not 
yet initiated personal invitations, and examinations in 2007. The totals in the table (5.5 million invited, 
and  9.9  million  screened)  do  not  include  persons  invited  to  the  population-based  screening 
programme being rolled out in Scotland. Data on the number of women and men attending screening 
is  lacking  from  the  non-population-based  programmes  in  Austria,  Bulgaria,  Greece,  Latvia  and  the 
Slovak Republic. Furthermore, the number of personal invitations and the total number of women and 
men attending screening was rapidly increasing in the five Member States rolling out population-based 
programmes for a total target population of 46 million women and men. If these factors are taken into 
account, a conservative estimate would yield over 8 million women and men personally invited to, and 
over 12 million women and men attending colorectal cancer screening programmes in the EU in 2007. 
The  FOBT  was  the  screening  test  used  in  more  than  9  out  of  10  screening  examinations  (approxi-
mately 94%). 

3.3.6  Volume of non-programme screening 

The  volume  of  colorectal  cancer  screening  examinations  performed  outside  of  publicly  mandated 
screening  programmes  has  been  reported  for  only  four  of  the  27  EU  Member  States  (1.7  million 
examinations annually in France, Germany, Latvia and Portugal). The available data is insufficient to 

27 Note that the recommended age range for FOBT screening may be of limited relevance in the case of endoscopic 

colorectal cancer screening. 

28 Note regional variation in the youngest age targeted for FOBT screening in the United Kingdom (Table 5 b). 

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estimate  the  actual  volume  of  non-programme  examinations  in  the  EU,  although  the  number  of 
examinations is likely to be substantially higher. 

4  Qualitative information on implementation of cancer screen-

ing in the EU Member States 

The broad and complex scope of activities involved in establishing and running appropriate and effect-
tive cancer screening programmes is reflected in the numerous points grouped under six headings in 
the  Council  Recommendation.  Twenty-two  of  the  23  points  can  be  broken  down  further  into  30 
specific recommendations incorporated in the Council Recommendation which deal with the manner in 
which population-based screening programmes are implemented, managed, monitored, and adopted 
or changed. They have been covered by a total of 31 items in 22 of the 23 questions included in sec-
tion III of the questionnaire used in the presently reported survey. The first question in section III of 
the  questionnaire  dealing  specifically  with  whether  or  not  population-based  breast,  cervical  or  colo-
rectal cancer screening has been implemented in a Member State has been covered in chapter 3 and 
therefore  will  not  be  reported  here.  The  remaining  qualitative  information  on  adherence  to  the  30 
respective  individual  recommendations  in  the  Council  Recommendation  which  has  been  reported  in 
the  questionnaires  received  from  22  Member  States  (see  section  2.2)  is  summarised  below  and  in 
Annex 5. Reported deviation from the specific recommendations is pointed out in sections 4.1 to 4.6, 
which correspond to the headings in the Council Recommendation (cf. Annex 2). 

Whereas eight out of 10 Member States reported that they followed at least two out of three specific 
recommendations  dealing  with  most  of  the  principles  in  the  Council  Recommendation,  this  level  of 
compliance  was  only  reported  by  4  out  of  10  Member  States  for  specific  recommendations  dealing 
with monitoring (41%) (cf. section 3 of Annex 2 and items 26 a and b, 27 and 28 of Annex 5) and 
scientific evaluation prior to introduction of novel screening tests (36%) (cf. section 6 of Annex 2 and 
questions  32 – 36 in Annex 5). Furthermore, a high proportion of the Member States (82%) reported 
that they follow the recommendation to provide human and financial resources to assure appropriate 
organisation and quality control (cf. section 1 of Annex 2 and item 18 a of Annex 5). Yet only 41% of 
the  Member  States  indicated  that  the  resources  being  provided  for  these  important  tasks  are 
satisfactory (cf. item 18 b of Annex 5). 

Twenty-five out of 30 of the specific recommendations (83%) were reported to be followed by at least 
one-half of the Member States which responded to the survey. Somewhat more than one-half of the 
recommended items (16 out of 30, 53%) were reported to be followed by more than two out three 
Member  States.  Most  exceptions  to  this  substantial  agreement  were  confined  to  the  specific 
recommendations in the Council Recommendation dealing with monitoring screening programmes and 
introduction of novel screening tests (see sections 4.3 and 4.6). 

A  notable  inconsistency  was  also  evident  in  the  high  proportion  of  the  responding  Member  States 
(82%)  reporting  that  they  follow  the  specific  recommendation  1  (e)  to make available human and 
financial resources to assure appropriate organisation and quality control, on the one hand, and the 
lower  proportion  of  responding  Member  States  (41%),  on  the  other  hand,  which  indicated  that  the 
resources being provided  for  these  important  tasks are satisfactory  (see  section  4.1  and  items  18 a 
and 18 b in Annex 5).  

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4.1  Implementation of cancer screening programmes 

Seven  out  of  nine  (nearly  80%)  of  the  specific  recommendations  in  the  first  section  of  the  Council 
Recommendation,  dealing  specifically  with  establishing  screening  programmes,  were  reported  to  be 
followed by at least two out of three Member States.  

In addition to the comparatively low proportion of responding Member States (41%) which considered 
the level of resources they provide for organisation and quality control of screening programmes to be 
satisfactory,  comparatively  low  agreement  with  the  Council  Recommendation  (50%)  was  only 
reported for one other specific recommendation in this section: assessment of side-effects and cost-
effects of screening  prior to …decisions on implementation of cancer screening programmes…  

4.2  Registration and management of screening data 

The specific recommendations in the Council Recommendation dealing with registration and manage-
ment  of  screening  data  were  reported  to  be  followed  by  very  large  proportions  of  the  responding 
Member  States.  Eighteen out  of  22  (82%)  used  centralised  data systems  and  call/recall  systems  for 
running  programmes  and  for  inviting  all  targeted  persons,  respectively.  Twenty  out  of  22  (91%) 
responding  Member  States  reported  that  data  is  collected,  managed  and  evaluated  not  just  on 
screening results, but also on assessment of persons with positive screening results and on diagnosis. 
The  same  high  conformity  was  reported  for  data  handling  in  full  accordance  with  European  data 
protection  legislation,  particularly  as  it  applies  to personal  health  data,  prior  to  implementing  cancer 
screening programmes. 

4.3  Monitoring 

Although a majority of the responding Member States indicated that they comply with two of the three 
specific  recommendations  in  the  section  of  the  Council  Recommendation  dealing  with  monitoring 
screening programmes, compliance was substantially lower than for most items in all other sections, 
except section 6. 

With  regard  to  specific  recommendation  3  (a)  in  the  Council  Recommendation,  only  55%  of  the 
responding  Member  States  reported  that  the  process and outcome of organised screening is 
monitored regularly by an independent peer review and 59% indicateed that the results are reported 
quickly to the general public and to screening staff.  The  lower  proportions  of  responding  Member 
States  performing  such  monitoring  reflect,  among  other  things,  the  limited  applicability  of  the 
respective questions in the EU survey to Member States in which population-based cancer screening 
programmes have not been initiated. The comparatively very low proportion of Member States which 
reported that national cancer registries monitor screening programmes (45%) can only be explained 
to a limited extent by the fact that other institutions are primarily responsible for screening monitoring 
although the responsible institutions, in turn, also make use of cancer registry data. 

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4.4  Training 

Very high compliance is reported for section 4 of the Council Recommendation dealing with training. 
Twenty out of 22 responding Member States (91%) reported that screening programme personnel is 
adequately trained at all levels to ensure that they are able to deliver high quality screening. However, 
the global nature of the single question posed in this category on the questionnaire suggests that the 
results should be interpreted with caution. 

4.5  Compliance 

Very high proportions of the Member States also indicated that they adhere to section 5 of the Council 
Recommendation.  Twenty  out  of  22  responding  Member  States  (91%)  reported  that a high level of 
compliance is sought from the eligible population when organised screening is offered. Eighteen out of 
22  responding  Member  States  (82%)  reported  that  action  is  taken  to  ensure  equal  access  to 
screening, taking due account of the possible need to target particular socio-economic groups. 

4.6  Introduction of novel screening tests 

Approximately  only  one-half  of  the  22  responding  Member  States  (50%)  reported  adherence  to  the 
respective  specific  recommendations  in  section  6  of  the  Council  Recommendation  dealing  with 
introduction of novel screening tests taking into account international research results.  The  only 
specific recommendation to which a substantial proportion of Member States (77%) indicated compli-
ance  was  6  (a): implement new cancer screening tests in routine health care only after they have 
been evaluated in randomised controlled trials.  Fourteen  of  the  responding  Member  States  (64%) 
indicated that they perform trials prior to implementation of a new screening test on at least one of 
the  topics  (treatment outcomes, clinical outcomes, side-effects, morbidity, and quality of life) 
specifically  recommended  in  section  6  (b)  of  the  Council  Recommendation,  whereby  little  variation 
was evident in the topic of investigation (41% to 55%). Similar proportions of the responding Member 
States (41% to 55%) indicated that they comply with the other specific recommendations in section 6 
dealing, for example, with such aspects as (c) pooling of trial results from representative settings in 
assessing the level of evidence  and  (d)  other relevant aspects in evaluating evidence on new 
screening tests, such as cost-effectiveness in different health care systems, and (e) consideration of 
modification of existing screening tests based on validation in routine health care, possibly using other 
epidemiologically validated surrogate endpoints (cf. Annex 5). 

Five of the six responding Member States with the largest target populations (France, Germany, Italy, 
Spain and the United Kingdom) indicated full or nearly full compliance with all of the specific recom-
mendations in this section of the Council Recommendation. Although most of the responding Member 
States with substantially smaller target populations reported little or no compliance with any specific 
recommendations  in  this  section  except  (a)  implementation of new screening tests only after 
evaluations in randomized controlled trials,  some  Member  States  with  significantly  smaller  target 
populations  also  indicated  that  they  comply  with  most  or  all  recommendations  (Czech  Republic, 
Netherlands, Slovenia and Sweden). 29 

29 EU guidelines for quality assurance of colorectal cancer screening are currently being developed, and EU guide-
lines  for  breast  and  cervical  cancer  screening  are  currently  being  updated  in  projects  coordinated  at  the  Inter-
national  Agency  for  Research  on  Cancer  and  co-funded  by  the  EU  Public  Health  programme  (no.  2005317, 
Development  of  European  Guidelines  for  quality  assurance  of  colorectal  cancer  screening;  and  no.  2006322, 
European cooperation on development and implementation of cancer screening and prevention guidelines). 

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5  Discussion 

5.1  Scope  of  the  first  report  on  implementation  of  the  Council  Recom-

mendation on cancer screening 

The present report provides an overview of the extent to which the EU Member States have adopted 
the policies advocated in the Recommendation of the Council of the European Union of 2 December 
2003  on  Cancer  Screening.  The  Council  Recommendation  comprises  a  catalogue  of  twenty-three 
points, 22 of which can be broken down into 30 specific items, with special relevance to efforts aimed 
at  achieving  and  maintaining  an  appropriate  balance  between  benefit  and  harm  of  screening  large 
numbers  of  individuals  of  average  risk  in  the  population.  Given  the  number  and  complexity  of  the 
numerous  points,  and  the  current  lack  of  resources  which  would  be  required  to  objectively  analyze 
and compare the quality of cancer screening programmes in the EU, no attempt is made to measure 
the  performance  of  screening  programmes  for  this  initial  report.  It  is  recognised,  however,  that  the 
population-based  approach  is  the  fundamental  principle  which  is  recommended  by  the  Council  and 
which provides the organisational, professional and scientific framework for implementing and contin-
uously improving cancer screening programmes of appropriate quality. For the present overview, data 
has  therefore  been  collected  on  the  type  and  implementation  status  of  screening  programmes 
currently running or being established in the Member States. 

In light of the relatively short duration of time which has expired since adoption of the Council Recom-
mendation, on the one hand,  and the end of the presently reported period (in most cases the end of 
2007)  on  the  other  hand, the  catalogue  of  evidence-based screening  tests and procedures  currently 
recommended by the Council has not been systematically reviewed for the preparation of the present 
report.  Current  efforts  in  the  European  Cancer  Network  to  develop  and  update  European  quality 
assurance  guidelines  for  breast,  cervical  and  colorectal  cancer  screening,  have  not  yet  indicated  a 
need  for  changes  in  the  catalogue  of  recommended  screening  tests.27  However,  relevant  develop-
ments may be forthcoming in the near future. A systematic review is therefore recommended prior to 
consideration of any changes in the current Council Recommendation. 

5.2  Impact  of  the  Council  Recommendation  on  screening  policies  in  the 

EU Member States 

The  experience  in  the  cancer  screening  networks  established  under  the  Europe  Against  Cancer  Pro-
grammes  has  shown  that  scientific  investigation  and  piloting  prior  to  nationwide  rollout  can  provide 
information essential to effective programme implementation [e.g., 32, 41, 44]. Furthermore, a long-
term  translational  phase  is  essential  to  successfully  plan,  pilot  and  rollout  population-based  cancer 
screening  programmes  across  an  entire  country,  and  particularly  also  across  several  countries.  The 
time frame depends, to a large extent, on the professional and organisational capacity which must be 
developed to successfully perform, monitor and evaluate high quality services integrating all steps in 
the  screening  process.  This  activity  not  only  entails  coordination  of  complex  communication  and 
training,  but  also  integration  of  multidisciplinary  teams  into  the  diagnosis  and  treatment  of  screen-
detected lesions, and integration of cancer registration and cancer registries into the monitoring and 
evaluation of programme performance. Even in countries with relatively small target populations, the 
magnitude  of  the  task  can  be  substantial,  compared  to  initially  available  resources.  Successful 
preparation and completion of the nationwide implementation process may require ten years or more. 

It  is  for  this  reason  that  the  full  impact  of  the  Council  Recommendation  on  the  implementation  of 
breast,  cervical  and  colorectal  cancer  screening  programmes  in  the  EU  could  not  be  assessed  from 

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data  collected  for  the  present  report  on  the  time  period  up  to  the  end  of  2007.  Nevertheless,  the 
present report documents considerable activities in the EU Member States aimed at following through 
on  the  Council  Recommendation  on  Cancer  Screening.  The  non-exhaustive  list  in  Annex  4  includes 
over  70  complex  actions  in  the  27  EU  Member  States  conducted  since  2003,  the  year  in  which  the 
Council  Recommendation  was  adopted.  These  actions  have  aimed  at  implementing  or  improving 
breast  (N=30),  cervical  (N=22),  or  colorectal  (N=25)  cancer  screening  programmes  in  particular  or 
have  facilitated  implementation  of  screening  in  general  (N=10).  Although  these  actions  have  been 
taken as a result of decisions at the national or regional level, and many actions were set in motion 
prior  to  adoption  of  the  Council  Recommendation,  the  discussion  leading  up  to  adoption  of  the 
Recommendation and the pan-European exchange between policy makers and experts stimulated by 
adoption  of this  Community  health  policy  are  likely to  have  had a  positive  impact  on  the  implemen-
tation of many of the respective actions. 

Furthermore, the large numbers of EU Member States which were running or establishing population-
based  breast,  cervical  and  colorectal  cancer  screening  programmes  in  2007  (N=22,  17,  and  12, 
respectively)  indicate  that  four  years  after  adoption  of  the  Council  Recommendation  there  was 
substantial agreement between the Member States in the enlarged EU and the Council on the health 
policy priority of establishing cancer screening programmes of appropriate quality. The scale of these 
activities  underlines  the  substantial  impact  which  actions  at  the  Community  level  can  have  on  the 
health of Europe's citizens. 

Only limited data is available from the literature which could shed additional light on the impact of the 
Council  Recommendation.  Comparison  with  the  present  report  is  impaired  by  differences  in  data 
sources and methodology of data collection, as well as by differences in definitions of screening pro-
grammes.  The  present  report  indicates  that  breast  cancer  screening  programmes  were  running  or 
being  established  in  26  of  the  27  EU  Member  States  in  2007.  Population-based  programmes  were 
running  or  being  established  in  22  Member  States  (section  3.1).  The  most  recently  available 
comparable  data  were  collected  by  the International Agency  for  Research  on  Cancer  in  2002  during 
preparation  of  the  IARC  handbook  on  cancer  prevention  dealing  with  breast  cancer  screening  [19], 
and  in  surveys  conducted  by  the  International  Breast  Screening  Network  (IBSN)  sponsored  by  the 
National  Cancer  Institute  in  the  USA  in  1998  and  2002  [21,  23].  The  IBSN  surveys  reported  on 
characteristics of population-based screening programmes in 20 and 23 countries, including 9 and 10 
current  EU  Member  States  respectively.  The  IARC  handbook  reported  that  in  2002  organised  breast 
screening  programmes  were  running  or  being  established  in  15  current  EU  Member  States,  six  of 
which  had  nationwide  (Finland,  France,  Luxembourg,  The  Netherlands,  Sweden  and  the  United 
Kingdom)  and  six  of  which  had  regionally  limited  programmes  (Belgium,  Denmark,  Ireland,  Italy, 
Portugal  and  Spain).  Pilot  programmes  were  reported  in  three  current  Member  States  (Greece, 
Germany, Hungary).  

Compared  to  the  available  data  for  2002,  quite  substantial  progress  has  been  made  in  further 
implementation of population-based breast screening programmes in the EU. Eight additional Member 
States  were  running  or  establishing  population-based  programmes  in  2007  (Austria,  Cyprus,  Czech 
Republic, Estonia, Malta, Poland, Romania, Slovenia). Nationwide rollout of population-based screen-
ing is currently complete in two of these Member States (Cyprus and Estonia). Moreover, one of the 
three  Member  States  which  were  piloting  breast  screening  programmes  in  2002  has  completed 
nationwide rollout (Hungary), and another Member State (Germany) is currently in an advanced stage 
of nationwide rollout. The same applies to a number of Member States which in 2002 were reported 
to  have  regionally  limited, organised  programmes  (Belgium,  Ireland,  Italy  and  Portugal).  Nationwide 
rollout has also been completed in Spain.  

The  presently  reported  data  indicate  that  cervical  cancer  screening  programmes  were  running  or 
being  established  in  25  of  the  27  EU  Member  States  in  2007  (section  3.2).  A  questionnaire  survey 
conducted  by  the  Epidemiology  Working  Group  of  the  European  Cervical  Cancer  Screening  Network 
and  the  International  Agency  for  Research  on  Cancer  between  August  and  December  2003  docu-

28 

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mented  a lesser number (N=14) of the current EU Member States in which national, regional or pilot 
cervical cancer screening programmes had been established prior to 2003 (Czech Republic, Denmark, 
Finland, France, Germany, Hungary, Italy, Lithuania, Luxembourg, The Netherlands, Slovenia, Spain, 
Sweden,  the  United  Kingdom)  [3].  In  one  other  Member  State  (Slovak  Republic)  a  screening 
programme  was  planned  but  not  yet  implemented  in  2003;  in  two  of  the  aforementioned  Member 
States, the status changed from pilot to national programme (Hungary) or from non-population-based 
to  population-based  programme  (Slovenia)  in  2003.  These  initiatives  presumably  benefited  from  the 
support  at  the  Community  level  for  implementation  of  cervical  cancer  screening  programmes 
expressed  in the  Council  Recommendation  and  from the  international  and  pan-European  discussions 
leading up to adoption of the Council Recommendation [e.g., 1, 8]. The data base in the 2003 survey 
(N=20 countries) did not cover all of the current EU Member States because only countries or regions 
were included which met eligibility criteria of mortality and/or incidence which permitted assessment 
of cervical cancer trends.  

The present report shows that 19 Member States are were running or establishing colorectal cancer 
screening programmes in 2007 (section 3.3). The respective number of current Member States report-
ed in an international survey conducted in 2003 and 2004 was much lower (N=6). The survey docu-
mented  35  colorectal  cancer  screening  initiatives  in  17  countries  as  of  May  2004  [7].    National  or 
regional programmes were only reported for the Czech Republic, Italy and Poland, and pilot projects 
were  found  in  France,  Italy,  Spain and  the  United Kingdom. The authors  of the  international  survey 
acknowledged  that  some  initiatives  world-wide  were  not  covered.  A  further  survey  of  40  national 
gastroenterology  societies  between  2004  and  2006  indicated  that  13  countries,  12  of  which  are  EU 
Member  States  (Austria,  Bulgaria,  Czech  Republic,  Finland,  France,  Germany,  Hungary,  Italy, 
Luxembourg, Poland, Slovak Republic, United Kingdom) were operating a colorectal cancer screening 
programme  [10].  Both  of  the  aforementioned  surveys  were  consistent  with  the  current  results 
showing a preponderance of FOBT-based as opposed to endoscopy-based colorectal cancer screening 
programmes in the EU.  

Although the above-mentioned, published reports must be interpreted with caution, they consistently 
show a markedly lower degree of screening programme implementation in the EU prior to adoption of 
the  Council  Recommendation  than  currently  is  the  case.  These  results  are  in  agreement  with  the 
notion  that  the  Council  Recommendation  has  had  a  positive  impact  on  implementation  of  breast, 
cervical  and  colorectal  cancer  screening  programmes  in  the  EU.  The  positive  experience  with  the 
Council Recommendation on Cancer Screening in encouraging successful implementation of complex 
population-based programmes reaching large segments of the European population, and the success 
of  these  programmes  in  providing  highly  specialized  multidisciplinary  services  integrating  a  broad 
range of health care providers, regulatory agencies and other institutions should be taken into account 
in future efforts to improve the control of cancer and other chronic disease in the EU.  

5.3  Current disparity in implementation of cancer screening in the EU 

Despite the wide support for cancer screening programmes which is evident in the EU four years after 
adoption of the Council Recommendation it should be recognised that there is still substantial disparity 
between the Member States in implementation of cancer screening. This is reflected in the numbers of 
Member  States  in  which  nationwide  rollout  of  population-based  screening  programmes  was  still 
ongoing  at  the  end  of  2007,  or  had  yet  to  begin  because  breast,  cervical  and  colorectal  screening 
programmes  were  regionally  limited  or  only  in  the  piloting  or  planning  phase  (N=11,  8  and  12, 
respectively).  Furthermore,  non-population-based  breast,  cervical  and  colorectal  cancer  screening 
programmes  were  still  conducted  in  several  Member  States  (N=5,  12  and  7,  respectively)  and  no 
programme implementation of any kind was known or planned in a number of Member States (N=1, 
2, and 8, respectively). 

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The social and economic implications and the potential for further improvement in the current imple-
mentation status of cancer screening programmes are also reflected in the estimated overall number 
of  screening  examinations  performed  in  the  EU  in  2007  (approximately  55  million  per  year).  Even 
though numerous screening programmes are still far from the level of activity which can be expected 
in the future, the current volume already exceeds half a billion screening examinations in the EU over 
a 10-year period. Given the large number of healthy individuals attending screening, even small im-
provements in effectiveness and efficiency can have a substantial impact on overall performance, and 
on the overall balance between benefit and harm, and between benefit and cost of screening. 

The  importance  of  continued  efforts  to  improve  cancer  screening  in  the  EU  is  illustrated  by  the  fact 
that,  despite  the  large  numbers  of  persons  already  attending  screening  programmes,  the  current 
annual  volume  is  less  than  one-half  of  the  minimum  annual  number  of  examinations  that  would  be 
expected if the screening tests specified in the Council Recommendation were available to, and were 
utilised  by  all  EU  citizens  of  respective  age:  approximately  125  million  examinations  per  year  for 
breast (30 million), cervical (27 million) and colorectal (68 million) cancer screening.30  

The data collected for the present report do not permit reliable estimation of the total costs of screen-
ing programmes in the EU. It should be kept in mind, however, that in most Member States, the cost 
of  performing  a  screening  test  (i.e.,  not  including  additional  costs  for  diagnosis  and  treatment  of 
screen-detected lesions) is in the two-digit euro range.  

5.4  Community added value through transition to population-based 

screening programmes 

A  potential  source  of  resources  for  further  improvement  could  be  mobilised  by  replacing  the  non-
population-based programmes in the EU which currently provide ca. 32 million screening examinations 
per year) with population-based programmes. The experience in the European cancer screening net-
works  has  shown  that  provision  of  screening  services  in  a  non-population-based  setting  is  generally 
inefficient  and  of  limited  effectiveness  and  should  be  discouraged.  Non-population-based  screening, 
depends  on  the  initiative  of  the  individual  woman  or  her  doctor  and  is  often  characterised  by  high 
coverage in selected parts of the population which are screened too frequently, coexisting with a low 
coverage  in  other  population  groups  with  less  socioeconomic  status,  and  heterogeneous  quality, 
resulting  in  limited  effectiveness  and  poor  cost-effectiveness  [2,  3,  5,  15,  39].  The  same  applies  to 
"wild"  screening  outside  of  any  programme,  the  current  volume  of  which  could  not  be  reliably 
estimated for the present report, but which may also be assumed to be substantial.  

The  population-based  approach  with  personal  invitation  of  each  eligible  person  in  the  target  popu-
lation also provides the organisational framework for improving the equity and accessibility of screen-
ing programmes by facilitating effective use of call/recall systems. Substantial community added value 
can  therefore  be  expected  from  replacing  current  non-population-based  screening  programmes  with 
more efficient population-based programmes following the EU guidelines. 

More than half of the approximately 55 million screening examinations performed in 2007 in the EU 
were provided for cervical cancer screening (32 million). The lion's share of these examinations was 
provided  by  non-population-based  programmes  (75%,  24  million).  In  most  of  these  non-population-
based programmes the ages at which women are eligible to attend screening substantially exceed the 
minimum age range recommended by the EU Guidelines (30-60 years), and the screening interval in 

30  Based on minimum respective age-range of target populations and average screening intervals for  breast (50-69, 

2-yearly), cervical (30-60, 4-yearly), and colorectal cancer screening (50-74, 2-yearly). 

30 

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these  programmes  is  frequently  much  shorter  than  the  3-5-year  interval  recommended  in  the  EU 
guidelines. Such relatively short screening intervals are not justified in light of present knowledge of 
the  natural  history  of  cervical  cancer,  particularly  the  duration  of  the  precancerous  stage  [3].    As  a 
result, women attending these screening programmes may be examined many times more often than 
in population-based programmes but without appropriate additional benefit despite the potential harm 
and additional cost of screening resulting from the higher number of examinations in a lifetime. 

5.5  Barriers to and prospects for further progress 

The  qualitative  data  collected  from  22  Member  States  for  the  present  report  could  not  be  validated 
with  the  available  resources.  They  provide,  however,  an  insight  into  current  barriers  to  implement-
tation of the Council Recommendation. Whereas a large majority of the Member States indicated that 
they  already  adhere  to  or  intend  to  adhere  to  many  of  the  items  in  the  Council  Recommendation, 
exceptions to this substantial agreement were reported for a number of points dealing with monitoring 
screening programmes and scientific investigation relevant to introduction of novel screening tests. In 
notable  contrast  to  the  high  proportion  of  Member  States  (82%)  reporting  that  they  follow  the 
recommendation to make available human and financial resources to assure appropriate organisation 
and quality control,  only  a  minority  of  the  responding  Member  States  (41%)  indicated  that  the 
resources being provided for these important tasks are satisfactory.31  

Key  initial  results  of  the  present  report  were  discussed  at  the  recent  Slovenian  EU  Presidency 
Conference  held  on  6-7  February  2008  in  Brdo.32  The  attending  policymakers  and  experts  in  cancer 
prevention from across the EU noted the substantial volume of breast, cervical and colorectal cancer 
screening examinations which will be performed in the EU over the next 10 years. The great potential 
of this effort to reduce the burden of disease through earlier detection and treatment of cancer was 
widely  acknowledged.  However,  a  much  larger  volume  of  screening  (more  than  one  billion  examin-
ations over a 10-year period) would be required to make effective breast, cervical and colorectal can-
cer screening available in all Member States. Furthermore, due to a lack of reliably collected and regu-
larly  reported  information,  too  little  is  currently  known  at  the  Community  level  about  the  quality, 
effectiveness and cost-effectiveness of this activity. 

Despite  the  need  for  further  efforts,  the  substantial  progress  made  in  the  implementation  of  cancer 
screening programmes in the EU since adoption of the Council Recommendation on Cancer Screening 
should not be overlooked. The positive experience with the Council Recommendation in encouraging 
successful implementation of complex population-based programmes reaching large segments of the 
European  population  with  highly  specialized  multidisciplinary  services  integrating  a  broad  range  of 
health care providers, regulators and other institutions should be taken into account in future efforts 
to improve the control of cancer and other chronic disease in the EU.  

In  particular,  future  Community  efforts  should  recognize  the  importance  of  a  translational  phase 
permitting appropriate integration of new preventive or therapeutic strategies into existing health care 
systems and programmes. Furthermore, the effectiveness of appropriately integrated strategies under 
“real  life”  conditions  should  be  demonstrated  before  new  programmes  or  modifications  of  existing 

31 In  several  cases,  no  response  was  provided  to  individual  items  in  these  categories.  In  such  cases,  it  is  unclear 
whether  the  lack  of  response  reflects  a  negative  answer,  or  the  perception  of  the  person  filling  in  the  survey 
questionnaire that the respective question was of limited relevance or applicability. 

32 The increasing burden of cancer - How can it be reduced?  European  conference  held  in  Brdo,  Slovenia,  6-8 

February 2008, under the auspices of the Slovenian Presidency of the Council of the European Union 

31

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programmes  are  considered  to  be  fully  established. Pan-European  collaboration  in  such  translational 
efforts  has  the  potential  to  accelerate  health  improvements  across  the  EU  by  avoiding  unnecessary 
duplication of effort and by focusing available resources on common problems.  

5.6  Recommendations  

Representatives  of  national  health  authorities  and  experts  in  cancer  prevention  from  across  the  EU 
also  discussed  recommendations  in  light  of  the  previous  experience  with  implementation  of  the 
Council  Recommendation  at  the  pan-European  conference  held  in  Brdo  in  February,  2008,  in  the 
framework  of  the  Slovenian  Presidency  of  the  Council  of  the  European  Union.33  There  was  wide 
consensus  that  regular,  systematic  monitoring,  evaluation  and  EU-wide  status  reporting  would 
promote the exchange of information on successful developments between Member States and would 
identify weak points requiring improvement. Software tools for uniform monitoring of breast screening 
programmes across the EU have been developed in the European Cancer Network and their feasibility 
in  comparing  data  between  programmes  has  been  demonstrated.  Further  efforts  should  be  under-
taken to make such tools available for cervical and colorectal cancer screening and to promote their 
routine use.34 

There  was  also  broad  consensus  between  policymakers  and  experts  attending  the  Slovenian  EU 
Presidency  Conference  that  the  present  situation  underlines  the  need  for  further  efforts  at  the 
European level to facilitate implementation of the Council Recommendation.  

The experts and policymakers also concluded that substantial support will be needed for collaboration 
and cooperation between Member States and at the Community level in providing professional, organ-
isational  and  scientific  assistance  to  those  Member  States  seeking  to  establish  and  improve  popula-
tion-based  cancer  screening  programmes.  There  was  consensus  that  EU  structural  funds  should  be 
one  of  the  sources  of  resources  fur  such  assistance.  Furthermore,  a  process  should  be  identified  to 
improve accessibility of these funds for programmes in need of support 

The  pan-European  consensus  documented  in  this  forum  is  in  agreement  with  current  Commission 
policies to promote and improve the safety, effectiveness and cost-effectiveness of health services in 
the  EU.  Key  to  the  future  success  of  these  efforts  will  be  development  and  implementation  of  an 
objective and  reliable  EU-wide  accreditation/certification scheme for  cancer  screening,  diagnosis  and 
management.  This  would  stimulate  quality  improvement  and  would  recognise  those  services  which 
fulfil the European quality assurance guidelines. 

33 See footnote 32. 
34 SEED – the European Screening Evaluation Database (www.cpo.it/seed). This prototype web database and audit 
system based on individual records is capable of calculating at a local or regional level a number of process and 
early  impact  indicators  of  breast  cancer  screening..  SEED  should  contribute  to  the  standardisation  of  screening 
evaluation in Europe by facilitating joint data collection and multi-centre comparisons, and by helping individual 
programmes to build their documentation system and to evaluate their own performance in a standard way. 
QT  –  Audit  system  on  Quality  of  breast  cancer  diagnosis  and  Treatment  (www.cpo.it/qt).  This  is  a  Microsoft 
Access individual records database which is available in six languages. A web version is being piloted. QT is kept 
updated with guidelines and allows recording of data on all women recalled for assessment in a screening pro-
gramme or assessed for clinical suspicion. QT has been designed for and is being used by clinical breast units for 
monitoring diagnosis and treatment of breast lesions in symptomatic as  well as asymptomatic  women. Further-
more,  it  can  assist  cancer  registries  for  high  resolution  population  studies.  Within  the  EUNICE  project,  a  web 
database  for  aggregated  data  collection  and  the  monitoring  of  European  breast  cancer  screening  performance 
parameters is currently being piloted (www.qtweb.it/eunice). 

32 

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6  Conclusions 

The adoption of the Council Recommendation on Cancer Screening in 2003 is a prime example of the 
way in which agreement of joint priorities and principles of health policy at the Community level can 
stimulate  EU-wide  implementation  of  programmes  aiming  to  improve  the  health  of  the  European 
population. Four years after its adoption, most Member States have acted on the Council Recommend-
ation,  and  most  Member  States  intend  to  undertake  further  action  where  implementation  is  not  yet 
complete. 

The positive experience with the Council Recommendation in encouraging successful implementation 
of complex population-based programmes reaching large segments of the European population should 
be taken into account in future efforts to improve the control of cancer and other chronic disease in 
Europe. 

Despite the broad consensus at the Community level and among the Member States in the expanded 
EU  on  the  importance  of  population-based  screening as  a  tool  of  cancer  control,  considerable  effort 
will  be  required  over  the  coming  years  to  successfully  implement  current  policies  and  to  overcome 
existing barriers to successful programme implementation. 

Even though the number of individuals currently attending cancer screening programmes in the EU is 
still  far  from  the  level  which  can  be  achieved  in  the  future,  the  expenditure  in  human  and  financial 
resources  is already  considerable. The scale of  these  resources  and  the  challenge  of  maintaining  an 
appropriate  balance  between  benefit  and  harm  of  screening  call  for  an  adequate  strategy  at  the 
Community  level  to  ensure  that appropriate  professional,  technical  and  scientific  support  is  available 
to Member States seeking to close the current gap between the status quo, and the potential of future 
expansion of evidence-based screening programmes to improve the health of the population. 

Adequate  provision  should  also  be  made  for  the  translational  phase  of  investigation,  planning, 
prioritising, and piloting prior to nationwide rollout of programmes or programme modifications, and 
for  research  on  innovative  screening  tests  and  on  the  impact  of  screening  in  the  population.  This 
particularly  holds  for  potentially  more  effective  methods  than  the  currently  recommended  test  for 
colorectal  cancer  screening  (FOBT)  and  for  new  methods  of  testing  and  complementary  preventive 
approaches  (such  as  HPV  vaccination  and  testing  for  primary  and  secondary  prevention  of  cervical 
cancer).  New  preventive  strategies  should  neither  be  recommended  for  routine  use  in  population-
based programmes nor in clinical practice until efficacy, benefits, and adverse effects, as well as cost-
effectiveness, have been adequately investigated. 

Increased  exchange  of  information  and  collaboration  between  Member  States,  and  professional, 
organisational  and  scientific  support  for  Member  States  seeking  to  establish  or  improve  population-
based screening programmes will also be required to successfully implement the Community strategy.  

Assistance  should  be  based  on  an  appropriate  technical  and  expert  advisory  capacity,  as  well  as 
regular, systematic monitoring, evaluation and EU-wide status reporting on implementation of cancer 
screening programmes.  

Development and piloting of an EU-wide accreditation/certification scheme mandated by the Member 
States  and  based  on  EU  quality  assurance  guidelines  would  encourage  programmes  throughout  the 
EU to take the initiative to continuously improve performance and would help consumers to recognise 
which services achieve the EU standards. 

Given  the  current  need  for  professional,  organisational  and  scientific  support  for  Member  States 
seeking to implement or improve cancer screening programmes, adequate resources for appropriate 
Community actions are vital. 

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7  References 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

Advisory Committee on Cancer Prevention (2000) Recommendations on cancer screening in the 
European union. Eur J Cancer 36: 1473-1478 

A.  Anttila  and  P.  Nieminen  (2000)  Cervical  cancer  screening  programme  in  Finland      Eur  J 
Cancer  36(17)Ö 2209-2214, doi:10.1016/S0959-8049(00)00311-7 

Antilla A,  Ronco G,  Clifford G,  Bray F,  Hakama M,  Arbyn M  &  Weiderpass E.  (2005)  Cervical 
cancer screening programmes and policies in 18 European countries. Br J Cancer 91: 935−941. 

Arbyn  M,  Autier  P,  Ferlay  J  (2007)  Burden  of  cervical  cancer  in  the  27  member  states  of  the 
European Union: estimates for 2004. Ann Oncol 18: 1423-1425 

Arbyn  M  &  Oyen  H  v  (2004)  Analysis  of  individual  health  insurance  data  pertaining  to  pap 
smears, colposcopies, biopsies and surgery on the uterine cervix (Belgium, 1996-2000). IPH/EPI 
REPORTS  Nr. 
Public  Heatlh. 
– 
http://www.iph.fgov.be/epidemio/epien/index000.htm 

021.  Brussels: 

Scientific 

Institute 

2004 

of 

Arbyn M, Raifu AO, Autier P, Ferlay J (2007) Burden of cervical cancer in Europe: estimates for 
2004. Ann Oncol 18: 1708-1715 

Benson VS, Patnick J, Davies AK, Nadel MR, Smith RA, Atkin WS, on behalf of the International 
Colorectal  Cancer  Screening  Network  (2008)  Colorectal  cancer  screening:  A  comparison  of  35 
initiatives in 17 countries  Int J Canc 122: 1357-1367. DOI 10.1002/ijc.23273 

Boyle P, Autier P, Bartelink H, Baselga J, Boffetta P, Burn J, Burns HJ, Christensen L, Denis L, 
Dicato  M,  Diehl  V,  Doll  R,  Franceschi  S,  Gillis  CR,  Gray  N,  Griciute  L,  Hackshaw  A,  Kasler  M, 
Kogevinas M, Kvinnsland S, La Vecchia C, Levi F, McVie JG, Maisonneuve P, Martin-Moreno JM, 
Bishop JN,  Oleari  F,  Perrin  P,  Quinn  M,  Richards M, Ringborg U, Scully  C,  Siracka  E,  Storm  H, 
Tubiana  M,  Tursz  T,  Veronesi  U,  Wald  N,  Weber  W,  Zaridze  DG,  Zatonski  W,  zur  HH  (2003) 
European  Code  Against  Cancer  and  scientific  justification:  third  version  (2003).  Ann  Oncol  14: 
973-1005 

9. 

Boyle P, Ferlay J (2005) Cancer incidence and mortality in Europe, 2004. Ann Oncol 16: 481-488 

10.  Classen  M,  Lambert  R  (2008)  Colorectal  Cancer  Screening  in  Europe.  A  Survey  of  the 
International  Digestive  Cancer  Alliance  between  November  2004  and  March  2007.  Z 
Gastroenterol 2008; 46: 23-24. 10.1055/s-2007-963500 

11.  Council  of  the  European Union  (16  December 2003).  Council  Recommendation  of  2  December 

2003 on Cancer Screening (2003/878/EC). OJ L 327: 34-38 

12.  European Parliament, Committee on Women's Rights and Equal Opportunities JOENS (18 March 
the  European  Union 

2004).  European  Parliament  Resolution  on  Breast  Cancer 
2002/2279(INI). OJ C 68 E.: 611-617 

in 

13.  European  Parliament.  European  Parliament  Resolution  on  Breast  Cancer  in  the  Enlarged 

European Union. P6_TA(2006)0449. 2006. 

14.  European  Commission.  European  Guidelines  for  Quality  Assurance  in  Breast  Cancer  Screening 
and Diagnosis. Fourth edition Perry N, Broeders M, de Wolf C, Törnberg S, Holland R, von Karsa 
L,  Puthaar  E  (eds).  Office  for  Official  Publications  of  the  European  Communities,  Luxembourg, 
2006 

36 

34 
 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

15.  European Commission. European Guidelines for Quality Assurance in Cervical Cancer Screening. 
Second edition. Arbyn M, Anttila A, Jordan J, Schenck U, Ronco G, Segnan N, Wiener H, Herbert 
A,  Daniel  J,  von  Karsa  L  (eds)  Office  for  Official  Publications  of  the  European  Communities, 
Luxembourg, 2008 

16.  Ferlay  J,  Autier  P,  Boniol  M,  Heanue  M,  Colombet  M,  Boyle  P  (2007)  Estimates  of  the  cancer 

incidence and mortality in Europe in 2006. Ann Oncol 18: 581-592  

17.  Giorgi D, Giordano L, Ventura L, Frigerio A, Paci E, Zappa M (2007) Mammography screening in 

Italy: 2004 survey and 2005 preliminary data. Epidemiol Prev 31: 7-20 

18.  Hakama M, Coleman M P, Alexe D, Auvinen A (2008) Chap 4. Cancer Screening in: Coleman M 
P,  Alexe  D,  Albrecht  T,  McKee  M  (eds)  Responding  to  the  Challenge  of  Cancer  in  Europe. 
Ljubljana: Institute of Public Health of the Republic of Slovenia, pp. 69-92. 

19. 

International Agency for Research on Cancer. Breast Cancer Screening (2002) IARC Handbooks 
of Cancer Prevention (vol. 7). IARC Press, Lyon 

20. 

International  Agency  for  Research  on  Cancer  (2005)  Cervical  Cancer  Screening.  IARC 
Handbooks of Cancer Prevention (vol. 10). IARC Press, Lyon 

21. 

International Cancer Screening Network. Characteristics of Breast Cancer Screening Programs in 
19  ICSN  Countries  Responding  to  a  Survey  in  2002.  Accessed  at  http://appliedresearch. 
cancer.gov/icsn/breast/policies1.html on 26 April 2008 

22.  Karsa  L  v  (1995)  Mammographie  Screening  -  umfassendes,  populationsbezogenes  Qualitäts-
management  ist  hier  gefragt!  Mammography  screening  –  comprehensive,  population-based 
quality assurance is required! Zeitschrift für Allgemeinmedizin 71: 1863-1867 

23.  Klabunde C, Bouchard F, Taplin S, Scharpantgen S, Ballard-Barbash R (2001) Quality assurance 
for screening mammography: an international comparison. J Epidemiol. Community Health 55: 
204-212. doi:10.1136/jech.55.3.204 

24.  Malila  N,  Oivanen  T,  Hakama  M  (2008)  Implementation  of  Colorectal  Cancer  Screening  in 
Finland: Experiences from the First Three Years of a Public Health Programme. Z Gastroenterol 
46: 25-28. DOI: 10.1055/s-2007-963490 

25.  National Evaluation Team for Breast cancer screening (NETB) interim report 2006 (2006) Main 
results of breast cancer screening programme in The Netherlands. National Evaluation Team for 
Breast Cancer Screening in The Netherlands (NETB), Rotterdam 

26.  Nieminen P,  Kallio M,  Antilla A  &  Hakama M.  (1999)  Organised  vs  spontaneous  pap-smear 

screening for cervical cancer: a case control study. Int J Cancer 83: 55−58.  

27.  Olsen  AH,  Njor  SH,  Vejborg  I,  et  al.(2005)  Breast  cancer  mortality  in  Copenhagen  after 

introduction of mammography screening: cohort study. BMJ. 330(7485): 220-222. 

28.  Paci E, Duffy SW, Giorgi D, Zappa M, Crocetti E, Vezzosi V, Bianchi S and del Turco MR (2002a): 
Quantification  of  the  effect  of  mammographic  screening  on  fatal  breast  cancers:  The  Florence 
Programme 1990-96. Br J Cancer 87: 65-9. 

29.  Paci  E,  Giorgi  D,  Bianchi  S,  Vezzosi  V,  Zappa  M,  Crocetti  E  and  Rosselli  del  Turco  M  (2002b): 
Assessment of the early impact of the population-based breast cancer screening programme in 
Florence (Italy) using mortality and surrogate measures. Eur J Cancer 38: 568-73. 

35

35 
 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

30.  Paci E, Duffy S, Giorgi D, Zappa M, Crocetti E, Vezzosi V, Bianchi S, Cataliotti L, del Turco MR 
(2002) Are breast cancer screening programmes increasing rates of mastectomy? Observational 
study BMJ 2002;325:418 

31.  Parvinen  I,  Helenius  H,  Pylkkanen  L,  Anttila  A,  Immonen-Raiha  P,  Kauhava  L,  Rasanen  O  and 
Klemi  PJ  (2006):  Service  screening  mammography  reduces  breast  cancer  mortality  among 
elderly women in Turku. J Med Screen 13: 34-40. 

32.  Peris  M,  Espinas  JA,  Munoz  L,  Navarro  M,  Binefa  G,  Borras  JM  (2007)  Lessons  learnt  from  a 
population-based  pilot  programme  for  colorectal  cancer  screening  in  Catalonia  (Spain).  J  Med 
Screen 14: 81-86 

33.  Perry N, Broeders M, de Wolf C, Törnberg S, Holland R, von Karsa L (2008) European guidelines 
for  quality  assurance  in  breast  cancer  screening  and  diagnosis.  Fourth  edition  Summary 
Document. Ann Oncol. Oncol  19: 614-622  

34.  Peto J, Gilham C, Fletcher O, Matthews FE (2004) The cervical cancer epidemic that screening 

has prevented in the UK. Lancet 364: 249-256 

35.  Ransohoff DF (2005) Colon cancer screening in 2005: status and challenges. Gastroenterology 

128: 1685-1695 

36.  Rebolj  M,  van  Ballegooijen  M,  Berkers  LM,  Habbema  D  (2007)  Monitoring  a  national  cancer 
prevention  program:  successful  changes  in  cervical  cancer  screening  in  the  Netherlands.  Int  J 
Cancer 120: 806-812  

37.  Ronco G, Giubilato P, Naldoni C, Zorzi M, Anghinoni E, Scalisi A, Dalla PP, Zanier L, Federici A, 
Angeloni  C,  Prandini  S,  Maglietta  R,  Mancini  E,  Pizzuti  R,  Lossa  A,  Segnan  N,  Zappa  M  (2007) 
Extension  of  organised  cervical  cancer  screening  programmes  in  Italy  and  their  process 
indicators. Epidemiol Prev 31: 33-47 

38.  Ronco  G,  Giubilato  P,  Naldoni  C,  Zorzi  M,  et  al  (2006)  Activity  level  and  process  indicators  of 

organised programmes for cervical cancer screerning in Italy. Epidemiol Prev 30(1):S3 27-40) 

39.  Ronco G, Pilutti S, Patriarca S, Montanari G, Ghiringhello G, Volante R, Giordano L, R Zanetti R, 
Mancini  E,  Segnan  N  and  the  Turin  Cervical  Screening  Working  Group  (2005)  Impact  of  the 
introduction  of  organised  screening  for  cervical  cancer  in  Turin,  Italy:  cancer  incidence  by 
screening history 1992-98. Br J Canc 93: 376-378, doi:10.1038/sj.bjc.6602705 

40.  Segnan N,  Ronco G  &  Ciatto S.  (2000)  Cervical  cancer  screening  in  Italy.  Eur  J  Cancer  36: 

2235−2239 

41.  Segnan  N,  Senore  C,  Andreoni  B,  Arrigoni  A,  Bisanti  L,  Cardelli  A,  Castiglione  G,  Crosta  C, 
DiPlacido  R,  Ferrari  A,  Ferraris  R,  Ferrero  F,  Fracchia  M,  Gasperoni  S,  Malfitana  G,  Recchia  S, 
Risio  M,  Rizzetto  M,  Saracco  G,  Spandre  M,  Turco  D,  Turco  P,  Zappa  M;  SCORE2  Working 
Group-Italy  (2005)  Randomized  trial  of  different  screening  strategies  for  colorectal  cancer: 
patient response and detection rates. J Natl Cancer Inst 97: 347-357. 

42.  Swedish  Organised  Service  Screening  Evaluation  Group.  (2006)  Reduction  in  breast  cancer 
mortality  from  organized  service  screening  with  mammography:  1.  Further  confirmation  with 
extended data. Cancer Epidemiol Biomarkers Prev. 2006 15(1):45-51.  

43.  Swedish  Organised  Service  Screening  Evaluation  Group.  (2006)  Reduction  in  breast  cancer 
mortality from organized service screening with mammography: 2. Validation with new analytic 
methods. Cancer Epidemiol Biomarkers Prev. 2006 15(1):52-56.  

36 

36 
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUURROOPPEEAANN  UUNNIIOONN    ––    FFiirrsstt  RReeppoorrtt 

44.  UK Colorectal Cancer Screening Pilot Group (2004) Results of the first round of a demonstration 
pilot  of  screening  for  colorectal  cancer  in  the  United  Kingdom.  BMJ  doi:10.1136/bmj.38153. 
491887.7C 

45.  Zorzi  M,  Barca  A,  Falcini  F,  Grazzini  G,  Pizzuti  R,  Ravaioli  A,  Sassoli  dB,  Senore  C,  Sigillito  A, 
Vettorazzi  M,  Visioli  C  (2007)  Screening  for  colorectal  cancer  in  Italy:  2005  survey.  Epidemiol 
Prev 31 : 49-60 

46.  Zorzi M, Puliti D, Vettorazzi M, De Lisi V, Falcini F, Federico M, Ferretti S, Moffa IF, Mangone L, 
Mano MP, Naldoni C, Ponti A, Traina A, Tumino R, Paci E; IMPACT Working Group (2006) Mas-
tectomy rates are decreasing in the era of service screening: a population-based study in Italy 
(1997-2001). Br J Cancer 95: 1265-68. 

37

37 
 
 
 
 
 
FFiigguurreess  

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
Proportion of Deaths in the EU due to Cancer in 2006 

Women 
N = 2,407,298 

Men 
N = 2,406,699 

Other 
32% 

Cancer 
23% 

Other 
33% 

Cancer 
29% 

Circulatory 
disease 
45% 

Circulatory 
disease 
38% 

Figure 1 a. Proportion of deaths in the European Union in 2006 by gender and major cause of death (deaths 
due to cancer not including non-melanotic skin cancer, proportions in percent). 

Source: EUROSTAT 2007 

40 
 
 
 
 
 
 
Cases of Breast, Cervical and Colorectal Cancer in the EU in 2006 

Women 
N = 1,087,200 

Men 
N = 1,307,800 

Colon and rectum 
13%

Colon and rectum 
13% 

Other 
54% 

Other 
87%

Breast 
30%

Cervix 
3% 

Figure 1 b. Proportion of cancer cases in the European Union in 2006 by gender and type of cancer (except 
non-melanotic skin cancer, proportions in percent). 

Source:  incidence  estimates  by  IARC  adapted  from:  Arbyn  M,  Autier  P,  Ferlay  J  (2007)  Ann  Oncol  18:  1423-1425:  Arbyn  M, 
Raifu AO, Autier P, Ferlay J (2007) Ann Oncol 18: 1708-1715; Boyle P, Ferlay J (2005) Ann Oncol 16: 481-488: Ferlay J et al. 
(2007) Ann Oncol 18: 581-592.  

Deaths due to Breast, Cervical and Colorectal Cancer in the EU in 2006 

Women 
N = 536,700 

Men 
N = 690,100 

Colon and rectum
13% 

Other 
89% 

Colon and rectum
11% 

Other 
68% 

Breast 
17% 

Cervix 
3% 

Figure 1 c. Proportion of cancer deaths in the European Union in 2006 by gender and type of cancer (except 
non-melanotic skin cancer, proportions in percent). Percentages for women do not add up due to rounding. 

Source: mortality estimates by IARC (2007) adapted from: Arbyn M, Autier P, Ferlay J (2007) Ann Oncol 18: 1423-1425: Arbyn 
M, Raifu AO, Autier P, Ferlay J (2007) Ann Oncol 18: 1708-1715; Boyle P, Ferlay J (2005) Ann Oncol 16: 481-488: Ferlay J et al. 
(2007) Ann Oncol 18: 581-592 .  

41 
 
 
 
 
 
 
 
 
 
 
 
Breast cancer incidence in the EU Member States 2006 

Figure 2 a. Age-standardised rates of incidence of breast cancer (cases per 100,000 women-years) in the 27 
Member States of the European Union, ranked by increasing incidence, estimates for 2006 (direct standardisation 
using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  incidence)  to  yellow,  brown  and  red  (highest  incidence)  based  on 
distribution  of  incidence  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 64.8, 68.7, 74.1, 94.5, 122.2, 128.0, 131.4 cases per 100,000 

Lowest incidence in Romania (61.2/100,000) and Latvia (64.8/100,000) 

Highest incidence in Belgium (137.8/100,000) and Ireland (131.4/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

8 

42 
 
 
 
 
 
 
 
Breast cancer mortality in the EU Member States 2006 

Figure 2 b. Age-standardised rates of mortality of breast cancer (deaths per 100,000 women-years) in the 27 
Member States of the European Union, ranked by increasing mortality, estimates for 2006 (direct standardisation 
using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  mortality)  to  yellow,  brown  and  red  (highest  mortality)  based  on 
distribution  of  mortality  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 20.4, 20.5, 21.2, 24.6, 27.3, 30.3, 33.54 deaths per 100,000 

Lowest mortality in Spain (19.2/100,000) and Bulgaria (20.4/100,000) 

Highest mortality in Denmark (34.5/100,000) and Belgium (33.5/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

9 

43 
 
 
 
 
 
 
 
 
Cervical cancer incidence in the EU Member States 2004 

Figure 2 c. Age-standardised rates of incidence of cervical cancer (cases per 100,000 women-years) in the 27 
Member States of the European Union, ranked by increasing incidence, estimates for 2004 (direct standardisation 
using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  incidence)  to  yellow,  brown  and  red  (highest  incidence)  based  on 
distribution  of  incidence  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles6.0, 8.0, 9.5, 12.3, 19.6, 20.3, 21.7 cases per 100,000 

Lowest incidence in Finland (4.9/100,000) and Malta (6.0/100,000) 

Highest incidence in Romania (24.5/100,000) and Bulgaria (21.7/100,000) 

Source:  IARC  (ECN  and  EUNICE  projects,  2007);  incidence  estimates  adapted  from:  Arbyn  et  al  (2007)  Ann  Oncol  18:  1423-
1425: Arbyn et al. (2007) Ann Oncol 18: 1708-1715; Boyle P, Ferlay J (2005) Ann Oncol 16: 481-488: Ferlay et al. (2007) Ann 
Oncol 18: 581-592 

10 

44 
 
 
 
 
 
 
 
Cervical cancer mortality in the EU Member States 2004 

Figure 2 d. Age-standardised rates of mortality of cervical cancer (deaths per 100,000 women-years) in the 27 
Member States of the European Union, ranked by increasing mortality, estimates for 2004 (direct standardisation 
using the European reference population). 

Cutpoints  for  color  scale  from  green  (lowest  mortality  )to  yellow,  brown  and  red  (highest  mortality)  based  on 
distribution  of  mortality  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 2.6, 2.7, 3.6, 4.9, 8.9, 10.5, 12.4 deaths per 100,000.  

Lowest mortality in Finland (1.6/100,000) and Italy (2.6/100,000) 

Highest mortality in Romania (17.0/100,000) and Lithuania (12.4/100,000) 

Source:  IARC  (ECN  and  EUNICE  projects,  2007);  mortality  estimates  adapted  from:  Arbyn  et  al  (2007)  Ann  Oncol  18:  1423-
1425: Arbyn et al. (2007) Ann Oncol 18: 1708-1715; Boyle P, Ferlay J (2005) Ann Oncol 16: 481-488: Ferlay et al. (2007) Ann 
Oncol 18: 581-592 

11 

45 
 
 
 
 
 
 
 
Colorectal cancer incidence in women in the EU Member States 2006 

Figure 2 e. Age-standardised rates of incidence of colorectal cancer (cases per 100,000 women-years) in the 
27 Member States of the European Union, ranked by increasing incidence, estimates for 2006 (direct standardisa-
tion using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  incidence)  to  yellow,  brown  and  red  (highest  incidence)  based  on 
distribution  of  incidence  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 25.1, 25.4, 29.4, 34.3, 37.4, 46.0, 48.0 cases per 100,000 

Lowest incidence in Greece (21.3/100,000) and Spain (25.4/100,000) 

Highest incidence in Hungary (50.6/100,000) and Denmark (48.0/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

12 

46 
 
 
 
 
 
 
 
Colorectal cancer mortality in women in the EU Member States 2006 

Figure 2 f. Age-standardised rates of mortality of colorectal cancer (deaths per 100,000 women-years) in the 
27  Member  States  of  the  European  Union,  ranked  by  increasing  mortality,  estimates  for  2006  (direct 
standardisation using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  mortality)  to  yellow,  brown  and  red  (highest  mortality)  based  on 
distribution  of  mortality  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 11.3, 13.2, 14.5, 15.6, 17.4, 24.1, 24.4 deaths per 100,000 

Lowest mortality in Greece (10.8/100,000) and Finland (11.3/100,000) 

Highest mortality in Hungary (26.7/100,000) and the Slovak Republic (24.4/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

13 

47 
 
 
 
 
 
 
 
Colorectal cancer incidence in men in the EU Member States 2006 

Figure 2 g. Age-standardised rates of incidence of colorectal cancer (cases per 100,000 man-years) in the 27 
Member States of the European Union, ranked by increasing incidence, estimates for 2006 (direct standardisation 
using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  incidence)  to  yellow,  brown  and  red  (highest  incidence)  based  on 
distribution  of  incidence  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 39.2, 40.7, 49.2, 54.4, 61.9, 87.1, 94.4 cases per 100,000 

Lowest incidence in Greece (31.0/100,000) and Finland (39.2/100,000) 

Highest incidence in Hungary (106.0/100,000) and the Czech Republic (94.4/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

14 

48 
 
 
 
 
 
 
 
Colorectal cancer mortality in men in the EU Member States 2006 

Figure 2 h. Age-standardised rates of mortality of colorectal cancer (deaths per 100,000 man-years) in the 27 
Member States of the European Union, ranked by increasing mortality, estimates for 2006 (direct standardisation 
using the European reference population) 

Cutpoints  for  color  scale  from  green  (lowest  mortality)  to  yellow,  brown  and  red  (highest  mortality)  based  on 
distribution  of  mortality  among  the  27  EU  Member  States  (5th,  10th,  25th,  50th,  75th,  90th,  and  95th 
percentiles): 17.8, 19.3, 23.4, 26.6, 30.2, 43.3, 51.0 deaths per 100,000 

Lowest mortality in Greece (15.5/100,000) and Finland (17.8/100,000) 

Highest mortality in Hungary (54.4/100,000) and the Czech Republic (51.0/100,000) 

Source: IARC (ECN and EUNICE projects, 2007); Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Ann Oncol 
18: 581-592 

15 

49 
 
 
 
 
 
 
 
Distribution of Breast Cancer Screening Programmes Based on Mammography 
in the EU in 2007 

Figure  3  a.  Breast  screening  programmes  in  the  European  Union  in  2007,  by  programme  type  (population-
based; non-population-based; no programme) and country implementation status (population-based: nationwide 
or regional, rollout complete or ongoing, piloting and/or planning; non-population-based: nationwide or regional). 
Programmes shown use screening test (mammography) recommended by the Council of the European Union in 
2003 (see Annex 2). For definitions see the text (section 2.3).  

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

50 
 
 
 
 
 
 
 
Number of EU Member States by Type and Status of 
Breast Screening Programmes 2007 

               No programme 

   Non-populaton-based 
       Nationwide 

1 

5*

11 

Population- 
based 

Nationwide 
   Rollout complete 

Nationwide 

   7 Rollout ongoing 

   1 Piloting* 
   3 Planning 

11* 

Population- 
based 

*One Member State with dual status

Figure 3 b Number of EU  Member States with breast cancer screening programmes in 2007, by type of pro-
gramme  and  country  implementation  status.  Numbers  do  not  add  up  to  27  due  to  dual  programme  type  of 
Austria. For definitions of programme type and status see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

50-69-year-old Women in the EU by Type and Status of 
Breast Screening Programmes 2007 

                                   2% Excluded 
                   2% No programme 
Non-populaton-based 

6% 

N= 59 Million 

41% 

Population- 
based  

Nationwide 
Rollout complete 

Nationwide 
44% Rollout ongoing 
  2% Piloting 
  5 % Planning 

50% 

Population- 
based 

Figure 3 c. Proportion of 50-69-year-old women in the European Union targeted for breast cancer screening in 
2007, by programme type and country implementation status, and women excluded due to age (proportions of 
50-69-year-old women in the EU population in %). Numbers do not add up to 100% due to dual programme type 
of Austria and due to rounding. For definitions of programme type and status see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

51 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Distribution of Cervical Screening Programmes based on Cervical Cytology 
in the EU in 2007 

Figure 4 a. Cervical cancer screening programmes in the European Union in 2007, by programme type (popula-
tion-based; non-population-based; no programme) and country implementation status (population-based: nation-
wide or regional, rollout complete or ongoing, piloting and/or planning; non-population-based: nationwide or re-
gional). Programmes shown use screening test (PAP smear) recommended by the Council of the European Union 
in 2003 (seen Annex 2). For definitions see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

52 
 
 
 
 
 
 
 
Number of EU Member States by Type and Status of 
Cervical Screening Programmes 2007 

2 No programme

2 

7 

Rollout complete 
    Nationwide  

(a)

11 Nationwide 
(b) 

  1 Regional 

12 

Non-population-
based 

Population-
based  

10 

Population-
based 

(a-d)

 4 Member States with dual type/status 

Nationwide 
   3 Rollout ongoing  
   2 Planning 
   1 Piloting & Planning 

(c),(d) 

Regional,  
   2 Rollout complete
   1 Rollout ongoing (d) 
   1 Piloting (a)

(b) (c)

Figure 4 b. Number of EU Member States with cervical cancer screening programmes in 2007, by type of pro-
gramme and country implementation status. Numbers do not add up to 27 due to dual types of France and Spain 
and dual status of Ireland and Portugal. For definitions of programme type and status see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

30-60-year-old Women in the EU by Type and Status of 
Cervical Screening Programmes 2007 

                   2% Excluded 
< 1% No programme 

2% 

Rollout complete 
   Nationwide 

N= 109 Million 

  7% Regional 
41% Nationwide 

47% 

Non-
pop.ulation- 
based  

22% 

Population-
based  

29% 

Population-
based 

       Rollout ongoing 
           20% Nationwide 
       Planning / Piloting 
            7% Nationwide 
        Regional 2% 

Figure 4 c. Proportion of 30-60-year-old women in the European Union targeted for cervical cancer screening 
in  2007,  by  programme  type  and  country  implementation  status,  and  women  excluded  due  to  age  or  lack  of 
regional programmes in countries with regional implementation status (proportions of  30-60-year-old women in 
the EU population in %). For definitions of programme type and status see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

53 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Distribution of Colorectal Cancer Screening Programmes based on the 
Faecal Occult Blood Test in the EU in 2007 

Figure 5.  Colorectal  cancer  screening  programmes  based  on  FOBT  (faecal  occult  blood  test)  in  the  European 
Union in 2007, by programme type (population-based; non-population-based; no programme) and country imple-
mentation  status  (population-based:  nationwide  or  regional,  rollout  complete  or  ongoing,  piloting  and/or  plan-
ning;  non-population-based:  nationwide  or  regional).  Programmes  shown  use  screening  test  recommended  by 
the Council of the European Union in 2003 (see Annex 2). For definitions see the text (section 2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

54 
 
 
 
 
 
 
 
 
 Distribution of Colorectal Cancer Screening Programmes based on Novel 
Screening Tests still under Evaluation (Endoscopy) in the EU in 2007 

Figure 6. Colorectal cancer screening programmes based on novel screening tests still under evaluation (Endos-
copy)  in  the  European  Union  in  2007,  by  programme  type  (population-based;  non-population-based;  no  pro-
gramme) and country implementation status (population-based: nationwide or regional, rollout complete or ongo-
ing, piloting and/or planning; non-population-based: nationwide or regional). Programmes shown use screening 
tests based on methodology different from that recommended by the Council of the European Union in 2003 (see 
Annex 2). For definitions see the text (section 2.3).  

Abbreviations: FS (flexible sigmoidoscopy), CS (colonscopy). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

55 
 
 
 
 
 
 
 
 
 
Number of EU Member States by Type and Status of 
Colorectal Cancer Screening Programmes 2007 

8 

No 
programme 

12 

Population- 
based 

Nationwide 

  3 FOBT only 

  4 FOBT/CS 

7 

Non-population- 
based  

10 Nationwide 

 5 Rollout ongoing 

3 FOBT only 
1 FOBT/FS 
1 CS only) 

 1 Piloting 

 4 Planning 

1 FOBT/CS 

2 Regional 

Figure 7 a. Number of EU Member States with colorectal cancer screening programmes in 2007 by type of pro-
gramme  and  country  implementation  status.  In  each  respective  category  individual  countries  are  counted  only 
once. Abbreviations: FOBT, CS and FS (see legends of Figs. 5 and 6). MS (Member State). For definitions of pro-
gramme type and status see the text (section 2.3). 
Note:  the  FOBT  is  the  screening  test  recommended  by  the  Council  of  the  European  Union  in  2003 
(Annex 2). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007) 

50-74-year-old Women and Men in the EU by Type and Status of 
Colorectal Cancer Screening Programmes 2007 

22% 

Excluded 

No programme 

8% 

43% 

Population 
based 

Nationwide 

27% 

Non-population-
based 

N= 136 Million 

43% Nationwide 

- 34% Rollout ongoing 
- 2% Piloting 
- 6% Planning 

<1% Regional 

Figure 7 b. Proportion of 50-74-year-old women and men targeted for colorectal cancer screening in the Euro-
pean Union in 2007, by programme type and country implementation status, and women and men excluded due 
to  age  or  lack  of  regional  programmes  in  countries  with  regional  implementation  status  (proportions  of  50-74-
year-old persons in the EU population in %). For definitions of programme type and status see the text (section 
2.3). 

Source: European Commission (DG SANCO, 2007); IARC (ECN and EUNICE projects, 2007)  

56 
 
 
 
 
 
 
 
 
 
  
  
  
  
 
TTaabblleess  

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
Table 1

Burden of Breast, Cervical and Colorectal Cancer in Women
in the EU Member States

Cases and deaths and European age-standardized rates (E-ASR)
by cancer type and Member State

Breast cancer
(2006)

Cervical cancer
(2004)

Colorectal cancer
(2006)

incidence

mortality

incidence

mortality

incidence

mortality

cases
x 100

E-ASR

deaths
x 100

E-ASR

cases
x 100

E-ASR

deaths
x 100

E-ASR

cases
x 100

E-ASR

deaths
x 100

E-ASR

Austria

Belgium 

Bulgaria

Cyprus

Czech Rep

Denmark

Estonia 

Finland

France

Germany

Greece

Hungary

Ireland 

Italy 

Latvia

Lithuania

Luxembourg

Malta

Netherlands

Poland

Portugal

Romania

Slovak Republic

Slovenia

Spain 

Sweden

UK

totals 

47.8

90.9

36.3

3.7

56.6

41.2

6.4

40.9

469.1

91.5

137.8

74.0

88.4

84.8

122.6

71.1

119.8

127.4

15.5

26.1

11.2

1.0

20.3

13.5

2.6

8.2

113.0

675.7

121.2

175.4

63.7

76.4

26.7

434.2

10.1

15.1

3.1

2.3

123.0

165.7

63.4

79.1

21.4

11.2

229.9

71.8

448.4

3,313.9

81.8

118.0

131.4

105.3

64.8

68.7

116.9

94.5

128.0

74.1

103.5

61.2

69.7

87.5

93.6

125.8

122.2

18.6

22.9

6.5

112.9

4.4

5.9

0.8

0.6

32.7

51.3

15.9

32.6

6.8

4.1

59.9

14.3

120.2

896.7

24.6

33.5

20.4

22.1

26.7

34.5

26.0

20.5

25.9

26.5

21.7

30.3

29.3

24.0

26.4

25.8

23.4

23.0

29.8

20.9

21.0

23.9

21.2

28.6

19.2

21.1

27.3

5.1

6.9

9.1

0.5

11.7

4.5

1.6

1.4

40.8

55.6

4.8

9.7

1.7

31.3

1.6

4.3

0.3

0.1

7.0

40.8

9.8

28.6

5.8

2.1

21.1

4.8

32.3

343.3

10.9

12.0

21.7

13.1

20.2

15.2

20.3

4.9

11.7

12.3

8.0

18.0

8.6

9.5

11.5

20.1

13.2

6.0

8.0

19.2

17.2

24.5

20.3

19.6

9.5

9.7

9.8

2.5

3.7

5.0

0.3

5.0

1.8

0.8

0.6

15.6

25.8

2.1

5.6

0.8

10.9

1.7

2.8

0.1

0.1

3.1

22.2

3.8

21.4

2.3

0.7

7.8

2.5

14.3

163.3

4.4

4.9

10.5

6.2

7.4

5.0

8.9

1.6

3.8

4.4

2.7

8.9

3.7

2.6

10.0

12.4

4.1

3.4

3.0

9.6

5.6

17.0

7.4

5.1

3.0

3.6

3.6

20.8

30.0

18.5

1.3

35.2

19.5

3.9

12.6

182.2

332.4

19.9

40.9

8.6

166.9

5.7

8.6

1.2

1.0

49.5

72.0

26.4

37.3

14.3

5.5

90.8

27.8

163.7

1,396.5

30.9

34.3

31.3

29.0

46.0

48.0

33.9

29.4

36.8

45.1

21.3

50.6

36.9

30.3

28.7

32.5

36.1

36.2

43.9

27.7

30.9

25.1

42.6

36.3

25.4

37.4

34.8

12.0

15.4

9.7

0.7

19.5

10.8

2.1

5.3

75.4

140.2

10.5

23.0

3.9

82.7

3.6

4.4

0.6

0.5

21.9

48.3

15.8

22.4

8.6

3.0

56.5

12.8

71.8

681.1

15.6

15.4

15.0

14.5

24.1

24.1

16.6

11.3

13.2

16.5

10.8

26.7

15.6

13.9

16.8

15.7

14.6

18.4

17.4

17.4

17.5

14.5

24.4

17.3

14.6

15.4

13.9

Source: incidence and mortality estimates by IARC (2007) adapted from: Arbyn M, Autier P, Ferlay J (2007) Ann Oncol 18:
1423-1425: Arbyn M, Raifu AO, Autier P, Ferlay J (2007) Ann Oncol 18: 1708-1715; Boyle P, Ferlay J (2005) Ann Oncol 16:
481-488: Ferlay J et al. (2007) Ann Oncol 18: 581-592

58Table 2

Burden of Colorectal Cancer in Men
in the EU Member States

Cases and deaths and
European age-standardized rates (E-ASR)
by Member State
(2006)

incidence

mortality

Austria

Belgium 

Bulgaria

Cyprus

Czech Rep

Denmark

Estonia 

Finland

France

Germany

Greece

Hungary

Ireland 

Italy 

Latvia

Lithuania

Luxembourg

Malta

Netherlands

Poland

Portugal

Romania

Slovak Republic

Slovenia

Spain 

Sweden

UK

totals 

cases
x 100

26.9

34.3

22.8

1.5

51.2

19.7

3.2

12.1

216.0

373.7

23.6

56.0

12.4

211.2

5.2

8.4

1.5

1.1

55.4

76.2

37.5

45.1

20.0

7.4

145.6

30.0

200.9

1,699.0

E-ASR

57.6

53.3

49.6

41.2

94.4

61.0

50.0

39.2

59.8

70.2

31.0

106.0

65.2

52.0

47.0

53.1

61.9

51.5

61.2

43.1

58.9

40.7

87.1

69.0

54.4

49.2

54.9

deaths
x 100

13.9

16.5

12.7

0.7

27.1

9.9

1.7

5.4

86.6

143.2

12.1

28.7

5.6

97.0

3.0

4.6

0.6

0.5

23.6

55.1

19.5

26.2

9.8

4.2

77.7

13.1

84.7

783.5

E-ASR

29.3

25.2

26.5

19.3

51.0

30.3

26.6

17.8

23.2

26.7

15.5

54.4

29.4

23.5

27.7

28.8

26.1

23.4

26.3

31.5

30.2

23.5

43.3

39.6

28.2

20.7

22.8

Source: incidence and mortality estimates by IARC (2007), Ferlay J et al. (2007) Ann
Oncol 18: 581-592

59Table 3 a

Breast Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 50-69-year-old women in national target populations*

Population-based
programmes

Breast cancer screening programmesα
No programme

Non-pop.-based
programmes

Totals

status

women
(X 1000)

status

women
(X1000)

status

women
(X 1000)

countries 
(N)

women
(X 1000)

2
natw-pilot

3

980

4

5

6

7

natw-rollout cmp

1,230

natw

980

no prog

1,040

1
Austria** 

Belgium 

Bulgaria**

Cyprus

natw-rollout cmp

Czech Rep**

natw-rollout ong

Denmark

Estonia 

Finland

France

Germany

Greece

Hungary

Ireland 

Italy **

Latvia

Lithuania

natw-rollout ong

natw-rollout cmp

natw-rollout cmp

natw-rollout cmp

natw-rollout ong

natw-rollout cmp

natw-rollout ong

natw-rollout ong

Luxembourg

natw-rollout cmp

Malta**

natw-plan

Netherlands

natw-rollout cmp

natw-rollout ong

natw-rollout ong

natw-plan

natw-plan

natw-rollout cmp

natw-rollout cmp

natw-rollout cmp

Poland**

Portugal

Romania

Slovak Republic

Slovenia

Spain 

Sweden**

UK

Subtotal

-Dual typeƒ

Totals

80

1,380

680

100

480

7,230

10,400

1,110

330

7,340

50

30

1,930

4,650

1,280

2,610

250

4,200

1,110

6,860

54,310

natw

1,350

natw

natw

310

410

natw

640

8
1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

9

980

980

1,230

1,040

80

1,380

680

100

480

7,230

10,400

1,350

1,110

330

7,340

310

410

50

30

1,930

4,650

1,280

2,610

640

250

4,200

1,110

6,860

59,040

980

58,060

-

54,310

-

3,690

980

2,710

1040

-

1,040

28

1

27

Abbreviations: natw (nationwide), rollout cmp (rollout complete), rollout ong (rollout ongoing), pilot (piloting), 

plan (planning), reg (regional),  no prog (no progamme)

Sources: Survey DG SANCO 2007, ECN / EUNICE projects, other sources see footnotes of Table 3 b

α Programmes using the screening test recommended in the Council Recommendation of December 2003: mammography.

* 50-69-year-old women in national populations in the age group targeted for screening, adjusted for regional variation in 

targeted age range (Finland, Spain and UK) or due to nationwide exclusion of some age groups (Estonia 60-69 years, 

  Hungary 66-69, Ireland 65-69, and Malta 60-69). Population statistics EUROSTAT 2007, except Finland (Mass Screening

Registry 2005) and UK, (national statistics 2006).

 ƒ Dual type: women in Austria enterred twice in table due to simultaneous programme activities of different type.

** Austria: In addtion to piloting a national pop.-based screening programme, non-pop.-based screening is offered nationwide.

** Bulgaria: Preparation of National Cancer Control Strategy 2009-2019 deals with breast cancer screening programme.

** Czech Republic: Status changed to population-based in the year personal invitation was initiated (2007).

** Denmark: As of 31 December 2007 a nationwide screening programme based on 2-yearly mammography for women aged

  50 to 69 years has been established.

** Hungary: Complete programme rollout confirmed by Ministry of Health. 

** Italy:  In 2007 in all Italian regions, at least one pilot population-based programe has been implemented.

Additonal footnotes: See next page and Table 3 b.

60Table 3 a

Breast Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 50-69-year-old women in national target populations*

Population-based
programmes

Breast cancer screening programmesα
No programme

Non-pop.-based
programmes

Totals

status

women
(X 1000)

status

women
(X1000)

status

women
(X 1000)

countries 
(N)

women
(X 1000)

1

2

3

4

5

6

7

8

9

Number of member states and target populations by programme type, and status
- population size in absolute numbers -

Nationwide

rollout comlete

rollout ongoing

piloting

planning

Regional

No Prog.

Totals

Adjustments

-Dual typeƒ

Subtotal

+Excluded pop.~

Adjusted totals

Nationwide

rollout comlete

rollout ongoing

piloting

planning

Regional

No Prog.

Totals

Adjustments

-Dual typeƒ

Subtotal

+Excluded pop.~

Adjusted totals

11

7

1

3

22

22

22

24,380

26,060

980

2,890

54,310

54,310

1,317

55,627

5

5

1

4

4

3,690

3,690

980

2,710

2,710

1

1

1

1

16

7

1

3

1

28

1

27

1,040

1,040

1,040

1,040

27

28,070

26,060

980

2,890

1,040

59,040

980

58,060

1,317

59,377

Number of member states and target populations by programme type, and status
- population size in % 50-69-year-old women in EU -

11

7

1

3

22

22

22

41.1%

43.9%

1.7%

4.9%

91.5%

91.5%

2.2%

93.7%

5

5

1

4

4

6.2%

6.2%

1.7%

4.6%

4.6%

1

1

1

1

16

7

1

3

1

28

1

27

1.8%

1.8%

1.8%

47.3%

43.9%

1.7%

4.9%

1.8%

99.4%

1.7%

97.8%

2.2%

1.8%

27

100.0%

~ 50-69-year-old women excluded from target populations of countries running or establishing nationwide population-based 

screening programmes because entire 50-69 age range is not targeted in all or some regions in: Estonia, Finland, Hungary,

Ireland, Malta, Spain, UK

** Latvia: Adoption of National Cancer Control Programme and Action Plan (including actions for transition to 2-yearly 

  population-based mammography screening for women aged 50-69 beginning in 2009) expected in October 2008.

** Malta: In Dec. 2007, the national authorities decided to begin implementation of a breast screening programme in 2008.

** Poland: Status changed to population-based in the year personal invitation was initiated (2007).

** Slovenia: Rollout of nationwide population-based breast screening programme began in April 2008.

** Sweden: 60-70% of counties start at age 40. Approximately 50% of counties invite age group 70-74. 100% invite 50-69.

  Size of target population estimated to be 100% of age group 50-69 and 50% of age groups 40-49 and 70-74.

Additional footnotes: see previous page and Table 3 b.

61Table 3 b

Annual volume of breast cancer screening programmes in the EU Member States 2006
Women personally invited, women screened, screening interval, non-programme examinations,
and total size of national target populations by programme status

Breast  cancer screening programmesα

Non-programmeβ

Programme 

Age-eligible
national population*

Screening 
interval

Personally 
invited~

Screened‡

Tests / yr
(X 1000)

Age group
(years)

1

Austria**
Austria**
Belgium**
Bulgaria**
Cyprus
Czech Rep**
Denmark**
Estonia 
Finland
France**
Germany
Greece**
Hungary**
Ireland 
Italy**
Latvia**
Lithuania
Luxembourg
Malta**
Netherlands**
Poland**
Portugal**
Romania
Slovak Republic
Slovenia**
Spain**
Sweden**
UK**
-Dual statusƒ
Totals

Type

Country status

2
pop-bas
non-pop-bas
pop-bas
no prog
pop-bas
non-pop-bas
pop-bas
pop-bas
pop-bas
pop-bas
pop-bas
non-pop-b
pop-bas
pop-bas
pop-bas
non-pop-b
non-pop-bas
pop-bas
pop-bas
pop-bas
non-pop-b
pop-bas
pop-bas
non-pop-b
pop-bas
pop-bas
pop-bas
pop-bas

3
natw-pilot
natw
natw-rollout cmp
no prog
natw-rollout cmp
natw
natw-rollout ong
natw-rollout cmp
natw-rollout cmp
natw-rollout cmp
natw-rollout ong
natw
natw-rollout cmp
natw-rollout ong
natw-rollout ong
natw
natw
natw-rollout cmp
natw-plan
natw-rollout cmp
natw
natw-rollout ong
natw-plan
natw
natw-plan
natw-rollout cmp
natw-rollout cmp
natw-rollout cmp

Eligible  age†
(years)

4
40-69
40+
50-69

50-69
45-69
50-69
50-59
50-(59)69
50-74
50-69
40+
45-65
50-64
50-69
50-69
50-69
50-69
50-59(69)
50-75
50-69
45-69
50-69
40+
50-69 
(45)50-64(70)
40(50)-(69)74
50-(64)70

--

--

--

Women
(X 1000)

5

240
2,251
1,230

84
1,699
675
98
478
8,609
10,446
2,992
1,503
333
7,340
310
410
50
30
2,310
4,650
1,660
2,610
1,310
250
4,550
1,510
7,110
490
64,248

(years)

Women / year
(X 1000)

Women / year
(X 1000)

6
(1)2
2
2

2
2
2
2
2
2
2
(1)2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
3

--

7

8

9

10

7

620

30

52
42
240
4,480
510

580
83
1,950

47
23

1,090

250

2,010

2,170

180

14
250
39
21
210
2080
300

200
63
1170

54
15

892
540
140

1310

1690

9

50-69

1720

350

8

15
4

310

240
80

14,165

9,166

2,736

62Table 3 b: Annual volume of breast cancer screening programmes in the EU member states 2006 - Footnotes

Abbreviations: pop-b (populatoin-based), non-pop-b (non-population-based), and no prog (no programme), natw (nationwide), rollout cmp (rollout complete),
rollout ong (rollout ongoing), pilot (piloting), plan (planning), reg (regional), no prog (no progamme).
Source: EC survey DG SANCO (2007), IARC (ECN / EUNICE 2007). Other sources see below.

α Programmes using the screening test recommended in the Council Recommendation of December 2003: mammography. 
* Women in national populations in the age group targeted for screening, adjusted for regional variation in eligible age group. National population statistics from EUROSTAT

1 January 2007, except Finland (National Mass Screening Registry 2005), Spain (National Statistics Office 2005), Italy (2006, DG SANCO survey) and UK (national statistics 2006).

β Non-programme examinations: examinations performed and/or documented outside the framework of a screening programme, generally not distinguished from diagnostic 

examinations and in some cases involving age groups not eligible to attend screening.

 ~ Personal invitations issued to eligible women, generally by letter, but also subsequent to referral.
‡ Women for whom screening tests were performed in population-based or non-population-based programmes.
† Ages in parentheses only apply to some regions or differ from national recommendations.
 ƒ Dual status: women in national populations of Austria entered twice in table due to simultaneous programme activities of different type or status.
** Austria: 903,647 non-population-based screening examinations reported for 2006 without specification of target cancer (e.g. breast, colorectal or prostate).
  By the end of 2008, Austria plans to personally invite ca. 240,000 women to attend population-based breast screening pilots.
** Belgium: Updated invitation data for 2006 provided by the Breast Screening Reference Centre, Brussels, Belgium.
** Bulgaria: Preparation of National Cancer Control Strategy 2009-2019 deals with breast cancer screening programme.
** Cyprus:Documentation system is currently being revised. Complete rollout confirmed by the Ministry of Health, Cyprus. 
** Czech Republic: Status changed to population-based in the year personal invitation was initiated (2007). 2006 participants estimated from 2007 data of national coordination office.
** Denmark: As of 31 Dec.2007 a nationwide screening programme based on 2-yearly mammography for women aged 50 to 69 years has been established. Volume data from 2001 pilot.
** France: Opportunistic volume estimated from census report.
** Greece: Non-population-based mammography screening currently available annually to publically insured women 40-50 years old, and 2-yearly to women over age 50. National statistics
  not available. Introduction of pop.-based  mammography screening for women aged 50-69 foreseen in national cancer plan 2008-2012  which is under public consultation.
** Hungary: No of non-programme screening examinations currently only available for 2005 (348,589) Complete programme rollout confirmed by Ministry of Health. Eligible target population 
  significantly smaller than total target population due to exclusion of women with a mammogram in the previous 24 months.
** Italy: Data shown for age group 50-69. Some regions invite women up to age 74.
** Latvia: Adoption of National Cancer Control Programme and Action Plan (including actions for transition to 2-yearly population-based mammography screening for women aged 50-69 
  beginning in 2009) expected in October 2008.
** Malta: A three-yearly mammography screening programme for women age 50-59 years will begin in 2008 and will be extended later to the age group 60-69 years.
** Netherlands: No. of women invited and no. of women screened in 2006 updated from 2007 interim report of National Evaluation Team for breast cancer screening in the Netherlands.
** Poland:  Status changed to population-based in the year personal invitation was initiated (2007).
** Portugal: Invitation and examination data 2006 for mainland from Portugese Cancer League.
** Slovenia: Rollout of nationwide population-based breast screening programme began in April 2008.
** Spain:Eligible age to start screening 45 yrs. 6 regions, 50 yrs. In 12 regions. Eligible ager to stop screening 64 yrs. in 7, 65 yrs. In 4, 67 yrs. In 1, 69 yrs. in 5, and 70 yrs. in 1region.
  Total age-eligible national population estimated at 4,389,912 women in 2005 based on population statistics of the National Statistics Institute, Madrid.
** Sweden: No centralized coordination, data accessible only at county level. 60-70% of counties start at age 40. Screening interval 18 months in age group 40-49. Thus total number of 
  invited women in target group should not be divided by 2. Approx. 50% of counties invite age group 70-74. Target population estimated to be 100% of age group 50-69 ,+ 50% of age 
  groups 40-49 and 70-74. Complete rollout confirmed by Stockholm county screening coordination.
** UK except Northern Ireland (target age group 50-70 years) 3-yearly, older women can request free 3-yearly screening. 
** UK - Northern Ireland (target age group 50-64) 3-yearly, older women can request free 3-yearly screening. 
  Additional footnotes: See Table 3a.

63Table 4 a

Cervical Cancer Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 30-60-year-old women in national target populations*

Population-based 
programmes

Cervical cancer screening programmesα
No programme

Non-pop.-based
programmes

Totals

status

women
(X 1000)

status

women
(X 1000)

status

women
(X 1000)

countries
(N)

women
(X 1000)

2

3

4

natw

natw

natw

natw

natw

natw

natw

natw

natw

natw

natw

reg

1,140

290

1,130

560

2,250

880

80

13,420

3,670

8,200

2,350

500

4,700

4,700

1
Austria

Belgium 

Bulgaria**

Cyprus

Czech Rep

Denmark

Estonia 

Finland

France**

Germany

Greece

Hungary

Ireland**

Italy 

Latvia

Lithuania

Luxembourg

Malta

natw-rollout cmp

natw-rollout ong

natw-rollout cmp

reg-pilot

natw-rollout cmp

natw-plan

reg-rollout cmp

natw-rollout ong

Netherlands

natw-rollout cmp

Poland

natw-rollout ong

Portugal**

natw-plan

reg-rollout ong

natw-pilot

natw-plan

Romania

Slovak Republic

Slovenia

Spain 

natw-rollout cmp

450

reg-rollout cmp

Sweden**

natw-rollout cmp

UK

natw-rollout cmp

-Dual statusƒ

Subtotal

-Dual typeƒ

Total

-

560

1,870

13,100

-5,280

54,570

54,570

6

7

no prog

170

no prog

90

5
1,850

2,280

1,650

2,320

13,000

18,000

2,450

500

750

110

1,200

7,370

8
1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

9
1,850

2,280

1,650

170

2,320

1,140

290

1,130

13,000

560

18,000

2,450

2,250

880

80

13,420

500

750

110

90

3,670

8,200

2,350

500

4,700

4,700

1,200

450

7,370

560

1,870

13,100

-5,280

106,310

106,310

-

51,480

-

51,480

-3

29

-2

27

260

260

Abbreviations: pop-b (population-based), non-pop-b (non-population-based), no prog (no programme). 

natw (nationwide) rollout cmp (rollout complete), rollout ong (rollout ongoing), pilot (piloting), plan (planning),

reg (regional)

Sources: EC survey DG SANCO 2007, ECN / EUNICE projects, other sources see Table 4 b

* 30-60-year-old women in national populations, adjusted for regional variation in eligible age and not including women in

regions without screening programmes of a given type in countries with only regional programmes of the respective type

 ƒ Dual status: countries and women in national populations entered twice in table due to simultaneous programme 

activities of same type but different status (Ireland, Portugal and Romania). 

 ƒ Dual type: Countries entered twice in table (France and Spain) due to simultaneous programme activities of different type.

Total 30-60-year-old target populations of France and Spain enterred only once in table (13.2 and 7.6 million, respectively).

** Bulgaria: Preparation of National Cancer Control Strategy 2009-2019 deals with cervical cancer screening programme.

Additional footnotes: See next page and Table 4 b.

64 
Table 4 a

Cervical Cancer Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 30-60-year-old women in national target populations*

Population-based 
programmes

Cervical cancer screening programmesα
No programme

Non-pop.-based
programmes

Totals

status

women
(X 1000)

status

women
(X 1000)

status

women
(X 1000)

countries
(N)

women
(X 1000)

1

2

3

4

5

6

7

8

9

Number of member states and target populations by programme type, and status
- population size in absolute numbers -

Nationwide

rollout complete 

rollout ongoing

pilot & plan

planning

Regional

rollout complete 

rollout ongoing

piloting
No Prog.

Totals

Adjustments

-Dual statusƒ

 Subtotal

-Dual typeƒ

+Excluded pop.~

Adjusted totals

Nationwide

rollout complete 

rollout ongoing

pilot & plan

planning

Regional

rollout complete 

rollout ongoing

piloting
No Prog.

Totals

Adjustments

-Dual statusƒ

Subtotal

-Dual typeƒ

+Excluded pop.~

Adjusted totals

7

3

1

2

2

1

1

17

2

15

15

11

44,110

1

7,370

23,610

21,910

4,700

3,230

640

500

560

55,150

12

51,480

580

54,570

336

12

2

54,906

10

51,480

2,010

53,490

2

2

2

2

18

3

1

2

3

1

1

2

31

2

29

2

27

260

260

260

260

67,720

21,910

4,700

3,230

8,010

500

560

260

106,890

580

106,310

2,346

108,656

Number of member states and target populations by programme type, and status
- population size in % 30-60-year-old women in EU -

8

2

1

2

2

1

1

17

2

15

15

11

40.6%

1

6.8%

21.7%

20.2%

4.3%

3.0%

0.6%

0.5%

0.5%

50.8%

12

47.4%

0.5%

50.2%

0.3%

50.5%

12

2

10

47.4%

1.8%

49.2%

2

2

2

2

18

3

1

2

3

1

1

2

31

2

29

2

27

0.2%

0.2%

0.2%

0.2%

1

20.2%

4.3%

3.0%

7.4%

0.5%

0.5%

0.2%

98.4%

0.5%

97.8%

2.2%

100.0%

~ 30-60-year-old women excluded from national target population in regions without screening programmes in country with 

regional implementation only (Spain) or in countries not targeting full age range 30-60 years.

ƒ Dual status: See footnote in first page of table. Dual status of Romania not counted in second page of table due to joint 

category "Piloting and planning".

ƒ Dual type: See footnote on first page of table.

** France: Regional population-based pilot programmes are running in some regions.

** Ireland: Regional population-based programme, nationwide implementation planned for 2008

** Portugal: Invitation system introduced in central region 2007, nationwide rollout planned to begin 2008. 

Additional footnotes: See previous page and Table 4 b.

65Table 4 b

Annual volume of cervical cancer screening programmes in the EU Member States 2006
Women personally invited, women screened, screening interval, non-programme examinations,
and total size of national target populations by programme status

Cervical  cancer screening programmesα

Age-eligible
national population*

Screening 
interval
(years)

Personally 
invited~
Women / yr
(X 1000)

Screened‡

Women / yr
(X 1000)

Non-programme testsβ
Tests / yr
Age group
(X 1000)
(years)

Programme 

Type

Country status

2

3

non-pop-b
non-pop-b
non-pop-b
no prog
non-pop-b
pop-b
pop-b
pop-b
non-pop-b
pop-b
non-pop-b
non-pop-b
pop-b
pop-b
pop-b
pop-b
non-pop-b
non-pop.b
non-pop-b
no prog
pop-b
non-pop-b
pob-b
pob-b
pop-b
non-pop-b
pop-b
non-pop-b
pop-b
pop-b
pop-b
pop-b

natw
natw
natw
no prog
natw
natw-rollout cmp
natw-rollout ong
natw-rollout cmp
natw
reg-pilot
natw
natw
natw-rollout cmp
natw-plan
reg-rollout cmp
natw-rollout ong
natw
natw
natw
no prog
natw-rollout cmp
natw
natw-plan
reg-rollout ong
natw-pilot
natw
natw-rollout cmp
reg
reg-rollout cmp
natw-rollout cmp
natw-rollout cmp

1
Austria**
Belgium**
Bulgaria**
Cyprus**
Czech Rep**
Denmark*
Estonia 
Finland**
France**

Germany
Greece
Hungary**
Ireland**

Italy**
Latvia**
Lithuania**
Luxembourg
Malta**
Netherlands**
Poland**
Portugal**

Romania
Slovak Republic
Slovenia**
Spain**

Sweden
UK**
-dual statusƒ
Totals

Eligible  age†
(years)

4
18+
25-64 
31-65

 25-69
23-59
30-59
(25)30-60(65)
(20)25-65
(20)25(50)-65(74)
20+
20+
25-65
25-60
25-60
25-64
20-70
30-60
15+

30-60
25-59
25-64
25-64
25-65
18+
20-64
(18)30(35)-59(65)
(25)30-(50)65
23-60
(20)25-(60)64

Women
(X 1000)

5

3,510
2,840
1,890

3,230
1,360
290
1,290
16,300
740
34,100
4,580
2,950
1,080
90
16,500
820
750
200

3,670
9,740
2,990
480
6,080
2,180
630
9,460
630
2,240
16,400
6,650
146,450

--

--

--

6
1
3
2

1
3 & 5
5
5
3
3
1
1
3
3 & 5
3 & 5
3
3
3
1

5
3
3
3
5
1
3
3 or 5
3
3 & 5
3 & 5

--

7

8

9

10

250
246

300
6
190
4,630

15,800

45

20
1,120
120
90
230

500
370

100
8

200

20

30
270

690

6
2,900

100

780

30

90

70

30-59

6000

960

126

30

266
41

679

all ages
all ages

18+

4,370

390
4,000

315
1,165

23-60
25-75

9,290

28,620

9,650

--

66  Table 4 b. Annual volume of cervical cancer screening programmes in the EU member states 2006 - Footnotes
Abbreviations: pop-b (population-based), non-pop-b (non-population-based), and no prog (no programme). 
natw (nationwide), rollout cmp (rollout complete), rollout ong (rollout ongoing), pilot (piloting), plan (planning),
Source: Survey EC survey DG SANCO 2007, additonal status information from ECN / EUNICE projects. Other sources see below.

α Programmes using the screening test recommended in the Council Recommendation of December 2003: Pap smear. 
* Women in national populations, adjusted for national and regional variation in eligible age and not including women living in regions without screening programmes in countries 

only with regional implementation status. National population statistics from EUROSTAT 2007, except Finland (National Mass Screening Registry 12/2004), UK (national statistics)
2006), and pilot regions in France (National Cancer Institute, INCA, Paris)

β Non-programme Examinations: examinations performed and/or documented outside the framework of a screening programme, generally not distinguished from diagnostic 

examinations and in some cases involving age groups not eligible to attend screening

 ~ Personal invitations issued to eligible women, generally by letter, but also subsequent to referral
‡ Women for whom screening tests were performed in population-based or non-population-based programmes
† Ages in parentheses only apply to some regions or differ from national recommendations
 ƒ Dual status: Women 50-69 years in national populations of France, Ireland and Portugal entered twice in table due to simultaneous programme activities of different type or status
** Austria: 903,647 screening examinations reported for 2006 without specification of target cancer (e.g. breast, cervical, colorectal or prostate)
** Belgium: Some regional programmes use call/recall systems. Screening and diagnostic examinations and eligible age groups cannot be differentiated in the current data.
** Bulgaria: The non-population-based screening programme includes  annual prophylactic examinations covering various diseaes. In women over 18 years a gyne- 
  cological exam and cytological sampling (PAP smear) is recommended every 2 years. In 2007 1.16 milion exams were performed, including ca. 246.000 PAP smears.
** Cyprus: an ad hoc committee is developing plans for a nationwide population-based cervical cancer screening programme for women 30-60 years of age based on cytology.
** Czech Republic: Invitation systems are being tested (20,000 personally invited and 5,000 screened women in addition to non-pop.-based examinations in 2006)
** Denmark: Non-attenders are personally invited. National monitoring is currently being established. Complete rollout confirmed by national Ministry of Health. Screening 
  volume 2006 estimated from coverage reported in EUNICE project for 2004-2006 for age group 25-59. Age range extended to 59 to 65 years as of 31 December 2007.
** Finland: Size of target population and volume of examinations from Finnish Mass Screening Registry, 2005.
** France: 2 of the 4 regional pop.-based pilots follow a different age range (20-65 and 50-74). In the rest of France, the target age is 25-65, with the exception of the overseas
  departments (20-65), therefore 25-65 age range used for estimation of target population outside pilot regions. Data for pilot regions from INCA, Paris
** Greece: Publically insured, sexually active women entitled to annual Pap smear examination. Data not currently available from a loco-regionally organized programme serving 
  certain areas of the Peleponnesus. Introduction of pop.-based cervical cancer screening foreseen in National Cancer Plan 2008-2012 which is under public consultation. 
** Hungary: Low volume of screening examinations compared to invitations attributed by national authorities to incomplete follow-up data from professionals taking cervical samples.
** Ireland: The regional population-based programme includes direct entry of eligible women. A nationwide population-based based programme will be implemented in 2008
** Italy: Some programmes also invite women outside the age range 25-64. Data from Italian National Centre for Screening Monitoring
** Latvia: Annual volume of examinations extrapolated from data of 2nd, 3rd and 4th quarter in 2005. Adoption of National Cancer Control Programme and Action Plan 
  (including actions for transition to 3-yearly population-based cervical cytology screening for women) expected in October 2008.
** Lithuania: Population-based monitoring and evaluation is implemented.
** Malta: A significant volume of cervical cytological screening examinations is available in the pubic and the private health sector.
** Poland: Personal invitations were not issued until 2007. Transition to pop-based programme in 2007
** Portugal: Invitation system introduced in central region 2007, nationwide rollout planned to begin 2008. 
** Spain: Target population estimated for age range 25-65 in regions with non-population-based programmes
** Sweden: Nos. and proportions of programme and non-programme examinations reported by Swedish National Board of Health and Welfare for 2002. Complete rollout 
  confirmed by authors of recent national cervical screening audit: Andrea B, et al. (2008) JNCI 100: 622-629: doi:10.1093/jnci/djno99.
** United Kingdom: targeted age and screened interval vary by region (England 3 yearly screening age 25-49 and 5 yearly age 50-64, Northen Ireland:5  yearly age 20-64 

Scotland: 3 yearly age 20-60); invited women not including Scotland. Volume data from NHS National Coordination Office, Coordination offices in Northern Ireland, Scottland 
and Wales Cervical Screening Programmes 

** UK-Northern Ireland: No. of women invited and no. of women screened not directly comparable due to recent change in invitation policy.

Additional footnotes: See Table 4a.

671

Austria**

Belgium 

Bulgaria**

Cyprus**

Denmark

Estonia 

Finland

France

Germany**

Greece

Hungary

Ireland**

Italy 

Latvia 

Lithuania

Luxembourg

Malta**

Netherlands**

Poland**

Portugal**

Romania

Table 5 a

Colorectal Cancer  Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 50-74-year-old persons in national target populations*

Colorectal cancer screening programmesα

Test

Population-based
programmes

Non-population-
based

No programme

Totals

status

persons
(X 1000)

status

persons
(X 1000)

status

persons
(X 1000)

persons
(X 1000)

 coun-
tries
(N) 

2

3

4

5

6

7

2

FOBT

CS

FOBT

natw-plan

CS

natw-plan

2,210

2,210

2,340

natw

natw

natw

10

10

Czech Rep

FOBT

natw

3,010

FOBT

natw-rollout ong

FOBT

natw-rollout ong

570

16,600

FOBT

CS

FOBT

CS

natw

natw

natw

natw

24,500

18,800

3,180

3,180

FOBT

natw-pilot

2,630

FOBT

natw-rollout ong

13,800

FS

reg-rollout ong

80

FOBT

natw

630

no prog

2,880

no prog

no prog

1,540

370

no prog

940

no prog

no prog

no prog

no prog

870

120

120

4,460

8

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

9

2,210

2,210

2,880

2,340

10

10

3,010

1,540

370

570

16,600

24,500

18,800

3,180

3,180

2,630

940

13,800

80

630

870

120

120

4,460

7,500

2,520

5,800

1,360

1,360

490

210

220

7,600

-25,630

106,490

CS

natw-rollout ong

FOBT

natw-plan

FOBT

natw-plan

Slovak Republic FOBT

CS

FOBT

natw-plan

FOBT

reg-pilot

FOBT

reg-plan

FOBT

natw-rollout ong

Slovenia**

Spain**

Sweden**

UK

-dual prog/testƒ

Totals

7,500

2,520

5,800

490

210

220

7,600

-80

57,960

natw

natw-plan

1,360

1,360

-25,550

37,230

-6

27

11,300

Abbreviations: pop-b (population-based), no prog (no programme),  natw (nationwide) rollout cmp (rollout complete), 

rollout ong (rollout ongoing),  pilot (piloting), plan (planning), no prog (no progamme), FOBT (fecal occult blood test), 

CS (colonscopy), FS (flexible sigmoidoscopy)

α Note: Only the FOBT is the test recommended by the Council of the European Union in 2003 (Annex 2).

Source: European Commission, 2007 (DG SANCO); IARC, 2007 (ECN and EUNICE projects); other sources see below.

* 50-74-year-old women and men in the national population, adjusted for national and regional variation in eligible age and not 

including persons living in regions without screening programmes in countries with regional implementation status. National 

population statistics from EUROSTAT 2007, except, Italy, Spain, Sweden, UK (see Table 4 b).

ƒ Dual programme status or test: women and men  in national populations entered twice in table due to screening 

programmes of different implementation status or using different screening tests. Note that only in Cyprus is population 

targeted for endoscopic screening not in same age range targeted for FOBT screening.

Additional footnotes: see following page and Table 5 b.

68Table 5 a

Colorectal Cancer  Screening Programmes in the EU Member States 2007
Programme type, country implementation status and
estimated no. of 50-74-year-old persons in national target populations*

Colorectal cancer screening programmesα

Test

Population-based
programmes

Non-population-
based

No programme

Totals

status

persons
(X 1000)

status

persons
(X 1000)

status

persons
(X 1000)

persons
(X 1000)

 coun-
tries
(N) 

1

2

2

3

4

5

6

7

8

9

Number of member states and target populations by programme type, and status
- population size in absolute numbers -

Nationwide

rollout cmplete§

rollout ongoing

piloting
planning

Regional

  pilotting
  planning

No Prog

Totals

Adjustments

-Dual§ status/testƒ

Subtotal
+Excluded pop.~

Adjusted totals

Nationwide

rollout cmplete§

rollout ongoing

piloting
planning

Regional
piloting
planning

No Prog

Totals

Adjustments

-Dual status/testƒ

Subtotal

+Excluded pop.~

Adjusted totals

5

1

4

1
1

12

12

12

46,070

2,630

8,830

210

220

57,960

57,960

29,500

87,460

7

1

8

1

7

7

37,230

1,360

38,590

1,360

37,230

37,230

8

8

8

8

7

5

1

5

1

1

8

37,230

46,070

2,630

10,190

210

220

11,300

11,300

11,300

28

107,850

1

27

11,300

11,300

27

1,360

106,490

29,500

135,990

Number of member states and target populations by programme type, and status
- population size in % 50-74-year-old EU population -

5

1

4

1
1

12

12

12

33.9%

1.9%

6.49%

0.2%
0.2%

42.6%

42.6%

21.7%

64.3%

7

1

8

1

7

7

27.4%

1.0%

28.4%

1.0%

27.4%

27.4%

8

8

8

8

7
5

1

5

1
1

8.3% 8

8.3% 28

1

8.3% 27

27.4%
33.9%

1.9%

7.5%

0.2%
0.2%

8.3%

79.3%

1.0%

78.3%

21.7%

8.3% 27

100.0%

§ Respective age-matched target populations of Austria, Germany, Greece, Italy and The Netherlands enterred only once.
~ 50-74-year-old persons excluded from national target populations due to regional or national variation in the age group target-
ed for screening, or due to lack of screening programmes in some regions of countries with regional implementation status
** Austria: women may elect to attend FOBT screening yearly, FOBT and colonoscopy screening are not mutually exclusive.
** Bulgaria: Preparation of National Cancer Control Strategy 2009-2019 deals with colorectal cancer screening programme.
** Cyprus: invitation of men and women aged 50 yrs. to FOBT screening, and 55 years to CS screening will begin in 2008.
** Denmark: Results of an FOBT-based pilot study in 2005-2006 and international findings are being analyzed in a health 

technology assessment. Based on the HTA the National Board of Health will make a recommendation expected in June 2008

concerning nationwide colorectal screening programme.

Additional footnotes: see previous page and Table 5 b.

69Table 5 b

1

Austria**

Belgium**
Bulgaria**
Cyprus**

Czech Rep
Denmark**
Estonia 
Finland
France**
Germany**

Greece

Hungary
Ireland**
Italy**

Latvia 
Lithuania
Luxembourg
Malta**
Netherlands**
Poland**
Portugal**
Romania
Slovak Republic

Slovenia**
Spain**
Sweden**
UK

Annual volume of colorectal cancer screening programmes in the EU member states 2006
Women and men personally invited, women and men screened, screening interval, non-programme examinations,
and total size of national target populations by programme status
Colorectal  cancer screening programmesα

Programme 

Test

Age-eligible national population*

Non-programmeβ
Tests/yr
(X 1000)

Age group
(years)

Type

Country status

Type

Eligible age†
(years)

2
non-pop-b
non-pop-b
no prog
non-pop-b
pop-bas
pop-bas
non-pop-b
no prog
no prog
pop-bas
pop-bas
non-pop-b
non-pop-b
non-pop-b
non-pop-b
pop-bas
no prog
pop-bas
pop-bas
non-pop-b
no prog
no prog
no prog
no prog
pop-bas
pop-bas
pop-bas
non-pop-b
non-pop-b
pop-bas
pop-bas
pop-bas
pop-bas

3

natw
natw
no prog
natw
natw-plan
natw-plan
natw
no prog
no prog
natw-rollout ong
natw-rollout ong
natw
natw
natw
natw
natw-pilot
no prog
natw-rollout ong
reg-rollout ong
natw
no prog
no prog
no prog
no prog
natw-rollout ong
natw-plan
natw-plan
natw
natw-plan
natw-plan
reg-pilot
reg-plan
natw-rollout ong

4
FOBT
CS

FOBT
FOBT
CS
FOBT

FOBT
FOBT
FOBT
CS
FOBT
CS
FOBT

FOBT
FS
FOBT

CS
FOBT
FOBT
FOBT
CS
FOBT
FOBT
FOBT
FOBT

5
50+
50+

31+
50
55
50+

60-69
50-74
50+
55-74
50+
50+
50-70

50-69(70-75)
58 or 60
50+

50-65
50-70
50-74
50+
50+
50-69
50-69
60-69
(50)60-69(74)

Screening 
interval

(years or
times in LT)

Personally 
invited~

Persons/yr
(X 1000)

Screened
‡

Persons/yr
(X 1000)

7
1 or 2
10

1
1 in LT
1 in LT
2

2
2
1 & 2
10 (2 in LT)
5
5
2

2
1 in LT
1

10
2
2

10
2
2
2
2

--

8

9

10

11

240

17
1,120
6750
610

12

910
8

25
2,670

28

2,110
50

41

32

110

490

15

230

550

1,000

5

130

5,525

9,944

1,685

--

Persons
(X 1000)

6

2,860
2,860

5,940
10
10
3,670

570
16,590
31,410
18,840
2,150
2,150
100

14,220
80
790

7,500
2,520
5,800
1,630
1,630
490
210
220
7,600
-25,480
106,900

-dual status or testƒ

Totals

--

--

--

--

70 
Table 5 b. Annual volume of colorectal cancer screening programmes in the EU member states - Footnotes
Abbreviations - pop-bas (population-based), non-pop-b (non-population-based), no prog (no programme).
rollout cmp (rollout complete), rollout ong (rollout ongoing), pop-b (populatoin-based) pilot (piloting), plan (planning), reg (regional), no prog (no progamme). 
FOBT (fecal occult blood test), CS (colonscopy), FS (flexible sigmoidoscopy), yr (year), LT (lifetime)
α Note: Only the FOBT is the test recommended by the Council of the European Union in 2003 (Annex 2).

Source: European Commission, 2007 (DG SANCO); IARC, 2007 (ECN and EUNICE projects); other sources see below.except Finland (national screening registry 12/2004),
* Women and men in national populations, adjusted for national and regional variation in eligible age and not including persons living in regions without screening programmes in

countries with regional or pilot implementation status. National population statistics from EUROSTAT 2007, except: Italy (Italian national screening observatory, 2006), Sweden (Stockholm
Council cancer screening programme, 2007), UK (national statistics 2006)

β Non-programme examinations: examinations performed and/or documented outside the framework of a screening programme, generally not distinguished from diagnostic 

examinations and in some cases involving age groups not eligible to attend screening

~ Personal invitations issued to eligible women, generally by letter, but also subsequent to referral
‡ Tests performed in population-based or non-population-based programmes
† Ages in parentheses only apply to some regions or differ from national recommendations
ƒ Dual status or test: women and men in national populations entered twice in table due to screening programmes of different implementation status or using different screening tests. 

Note that only in Cyprus is population targeted for endoscopic screening not in same age range targeted for FOBT screening. 

  Austria, Belgium, Cyprus, Denmark: see footnotes Table 5 a
** Finland: Data from National Cancer Mass Screening Registry 2006
** France: Data from 19 of 23 departments with active programme: average participation rate in 19 depts.: 42%
** Germany: At age 55, FOBT screening interval changes from 1 to 2 years, and 2 screening colonoscopies in 10-year interval are offered as an alternative to FOBT. Persons

electing to participate in CS screening are not eligible for FOBT screening.

** Greece: Currently 5-yearly FOBT and/or CS screening covered by public insurance for persons age 50+. Statistics not available at national level in 2007.

Introduction of population-based,FOBT screening for age group 50-74 years foreseen in national  cancer plan 2008-2012 which is currently under public consultation

** Ireland: Expert committee has been appointed in 2007 to advise the national authorities on colorectal cancer screening
** Italy: National colorectal cancer screening recommendation indicates 2 acceptable tests (FOBT or FS). Most programmes offer FOBT alone. 4 programmes offer only FS.
  3 programmes offer FOBT to persons not accepting FS and in the age range 59-69.
** Latvia: National Cancer Control Programme and Action Plan currently under development (expected adoption: October, 2008). Plan includes actions for transition to annual, population-
  based screening using FOBT for the age group 50+ years beginning in 2009.
** Malta: colorectal cancer screening is included in draft national cancer control plan currently under consideration in Malta.
** Netherlands: 3 pilot studies dealing with FOBT (Amsterdam and Nijmegen), FOBT and FS (Rotterdam) and CS (Maastricht) involving a total of over 30,000 subjects were running

in 2007. Results will provide evidence for policy decision on nationwide implementation of screening.

** Poland: In addition to asymptomatic men and women age 50-65 years, screeing colonoscopy is offered to the following groups with elevated risk: persons age 40-65
  who have a close family member who has been diagnosed with colorectal cancer, persons aged 25-65 with hereditary nonpolyposis colorectal cancer (HNPCC).
  Size of target population enterred in table corresponds to 50-65-year age group.
** Portugal: Population-based screening will begin in the central region of Portugal early in 2008
** Slovenia: Population-based screening will begin in Slovenia early in 2008
** Spain: Routine implementation of colorectal cancer screening is not included in national cancer control plan, but loco-regional pilot programmes are running in some regions.
** Sweden: population-based screening will begin in the Stockholm region early in 2008
** UK: three regions (England, Scotland and Wales) serving over 95% of 50-74-year-old population in UK currently aim to implement population-based screening. Final
  decision pending in Northern Ireland although Dept. of Health plans to begin rollout before the end of 2008. Rollout in England began in 2006 (2-yearly FOBT, age 60-69),  
in Scotland in 2007 (2-yearly FOBT, age 50-74), will begin in Wales in 2008 (2-yearly FOBT, age 50-74). In England, residents  70+ years may request FOBT screening 
when programm reaches their region; phasing in of invitation to age 75 will begin in 2010. Due to current rollout phase, available data underestimate the volume of invitations
and examinations performed in 2007. Estimates for England based on Dept. of Health Statistics Oct. 2007 for previous 12 months. Data not yet available from Scotland.
Additional footnotes: See Table 5a .

71 
 
Table 6

Number of Persons attending Breast, Cervical and Colorectal
Cancer Screening Programmes
in the European Union in 2007
by Target Cancer and Programme Type

Persons attending screening programmes for

Breast Cancer

Cervical Cancer

Colorectal cancer

Total

persons
(X 1000)

% of 
column

persons
(X 1000)

% of 
column

persons
(X 1000)

% of 
column

persons
(X 1000)

% of 
column

1

2

3

4

5

6

7

8

9

Population-
based

Non-population-
based

11,262

97%

7,791

25%

3,519

30%

22,572

41%

343

3%

23,744

75%

8,120

70%

32,207

59%

Total

11,606

100%

31,535

100%

11,639

100%

54,780

100%

  Source: European Commission, 2007 (DG SANCO); IARC, 2007 (ECN and EUNICE projects); other sources see

  Tables 3 b - 5 b. 

* Estimates of volume of screening in 2007. Volumes in Tables 3 b - 5 b corrected for programmes with missing data

  and for programmes in rollout phase in 2007.

72AAnnnneexxeess  

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
AANNNNEEXX  11  

EECCNN  &&  EEUUNNIICCEE  PPAARRTTIICCIIPPAANNTTSS  

75  
  
  
  
76 
Annex 1: ECN and EUNICE participants 

Numerous experts have taken an active voluntary role in the European Cancer Network 
(ECN) and the European Network for Information on Cancer (EUNICE) by providing data 
on cancer screening. This data has been used to check the plausibility of, and to 
supplement the information provided by the EU Member States for the present report. The 
contributions of the network participants are gratefully acknowledged. 

Auni Aasmaa 
Estonian Cancer Screening Foundation, Tallin, Estonia 

Rosemary Ancelle-Park 
Direction générale de la santé, Paris, France 

Bengt Andrae 
Department of Obstetrics and Gynecology, Gävle Hospital, Gävle, Sweden 

Ahti Anttila 
Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland 

Marc Arbyn 
Unit of Cancer Epidemiology, Department of Epidemiology, Scientific Institute of Public Health, 
Brussels, Belgium 

Nieves Ascunce Elizaga 
Instituto de Salud Publica de Navarra, Pamplona, Spain 

Nikolaus Becker 
German Cancer Research Centre, Heidelberg, Germany 

Maria Jose Bento 
Liga Portugesa contra o Cancro, Porto, Portugal 

Christine Bergeron 
Laboratoire Pasteur Cerba, Cergy-Pontoise, France 

Miklós Bodó 
Semmelweis University, I. Pathological Institute, Budapest, Hungary 

Aleksandra Bonkowska 
Poland 

Mireille Broeders 
EUREF, Department of Epidemiology and Biostatistics, Radboud University Medical Centre, Nijmegen, 
The Netherlands 

Arkadiusz Chil 
Swietokrzyskie Cancer Center, Kielce, Poland 

Karel Chroust 
Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic 

Montserrat Corujo Quinteiro 
Programa Gallego de Deteccion Precoz del Cancer de Mama, Santiago de Compostela, Spain 

23

77 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dolores Cuevas 
Consellaria de Sanitat, Valencia, Spain 

Barbara Dabrowska 
Ministry of Health, Warsaw, Poland 

Miriam Dalmas 
National Registry of Malta, Guardamangia, Malta 

Jan Danes 
General Teaching Hospital, Prague, Czech Republic 

Peter Dean 
Department of Diagnostic Radiology, University of Turku, Finland 

Alexandra De Grave 
Centre de référence pour le dépistage du cancer du sein, Brussels, Belgium 

Silvia De Sanjosé 
Epidemiology and Cancer Registry, Catalan Institute of Oncology, Barcelona, Spain 

Chris De Wolf 
Agence pour le développement et évaluation des politiques de santé (ADSAN), Genève, Switzerland 

Emmanuel Diakomanolis 
Athens University, Greece 

Lajos Döbrőssy 
Office of Chief Medical Officer, Iklad, Hungary 

Wenancjusz Domagala 
Pomeranian Medical University, Szczecin, Poland 

Ludmila Engele 
Latvian Oncology Center, Department of Methodology and Strategy, Riga, Latvia 

Muriel Fender 
Association EVE, Illkirch, France 

Patricia Fitzpatrick 
National Cancer Screening Service, Dublin, Ireland 

Jacques Fracheboud 
Erasmus MC, Rotterdam, The Netherlands 

Karen Fredrix 
Flemish Public Health Administration, Belgium 

Alfonso Frigerio 
CPO Piemonte, Turin, Italy 

Béatrice Gairard 
ADEMAS Alsace, Illkirch, France 

Livia Giordano 
CPO Piemonte, Turin, Italy 

78 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Daniela Giorgi 
Unit of Epidemiology, Azienda Sanitaria Locale, Lucca, Italy 

Tatjana Golubajeva 
State Patient Fund under the Ministry of Health, Lithuania 

André-Robert Grivegnee 
Cancer Prevention and Screening Clinic, Institut Jules Bordet, Brussels, Belgium 

Roland Holland 
National Expert and Training Centre for Breast Cancer Screening, Nijmegen, The Netherlands 

Hakan Jonsson 
Oncological Centre, Umea University Hospital, Umea, Sweden 

Joseph Jordan 
National Health Service Cervical Cancer Screening Programme, Birmingham, United Kingdom 

Alena Kállayová 
Slovakia 

Stefanie Klug 
Institute of Medical Biostatistics, Epidemiology and Informatics Hospital of the University of Mainz 
Mainz, Germany 

Una Kojalo 
Latvian Cancer Registry, Riga, Latvia 

Laura Kotaniemi-Talonen 
Finnish Cancer Registry, Helsinki, Finland 

Mateja Krajc 
Epidemiology and Cancer Registries, Institute of Oncology, Ljubljana, Slovenia 

Juozas Kurtinaitis 
Lithuanian Cancer Registry, Vilnius, Lithuania 

Lesz Lancucki 
NHS Cancer Screening Programmes, Sheffield, United Kingdom 

Elsebeth Lynge 
Institute of Public Health, University of Copenhagen, Denmark 

Szilvia Mádai 
MaMMa Healthcare Institute, Budapest, Hungary 

Cédric Mahé 
Institut National du Cancer, Paris, France 

Ondrej Májek 
Institute of Biostatistics and Analyses, Brno, Czech Republic 

Elena Makrigiorgi 
Ministry of Health, Nicosia, Cyprus 

Nea Malila 
Finnish Cancer Registry, Helsinki, Finland 

79 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Jozica Maucec Zakotnik 
Health Care Center Ljubljana, Ljubljana, Slovenia 

Blanka Mikl Meznar 
Ministry of Health, Ljubljana, Slovenia 

E. Missouri 
Cyprus 

Therese Mooney 
National Cancer Screening Service, Dublin, Ireland 

Antonio Morais 
Administracao Regional de Sude do Centro, Coimbra, Portugal 

Luciana Neamtiu 
Institutul Oncologic "I. Chiricuta", Cluj-Napoca, Romania 

Pavlos I. Neophytou 
Mendel Center for Biomedical Sciences, Cyprus 

Maria Nicolaïdou 
Cyprus Breast Cancer Screening Programme, Cyprus 

Florian Nicula 
Institutul Oncologic "I. Chiricuta", Cluj-Napoca, Romania 

Andrej Nowakowsky 
Regional Coordinating Centre for Cervical Cancer Screening, Lublin Medical University, Lublin, Poland 

Lennarth Nyström 
Dept. of Public Health and Clinical Medicine, Umea University, Umea, Sweden 

Marian O'Reilly 
National Cancer Screening Service, Cervical Screening Programme, Limerick, Ireland 

Martti Pamilo 
Health Services Research Ltd., Helsinki, Finland 

Vayios Partassides 
Cyprus Breast Cancer Screening Programme, Cyprus 

Pavlos Pavlou 
Ministry of Health, Nicosia, Cyprus 

Zoltan Péntek 
MaMMa Healthcare Institute, Budapest, Hungary 

Marianne Perreau-Saussine 
Institut National du Cancer, Paris, France 

Niall Phelan 
National Breast Screening Programme, Dublin, Ireland 

Kamil Pohlodek 
Medical Faculty, Comenius University of Bratislava, Bratislava, Slovakia 

80 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antonio Ponti, CPO Piemonte 
Turin, Italy 

Maja Primic-Žakelj, Epidemiology and Cancer Registries, Institute of Oncology 
Ljubljana, Slovenia 

Matejka Rebolj, Erasmus MC, Department of Pubic Health 
Rotterdam, The Netherlands 

Margrit Reichel, Mammography Screening Center 
Wiesbaden, Germany 

Henny Rijken, Univ. Medical Centre Nijmegen 
Nijmegen, The Netherlands 

Elena Riza, University of Athens Medical School 
Athens, Greece 

Vitor Rodrigues, Breast Cancer Screening Programme 
Coimbra, Portugal 

Guglielmo Ronco, Unit of Cancer Epidemiology, CPO Piemonte 
Turin, Italy 

Lola Salas Trejo, Conselleria Sanitat - Plan de Cancer 
Valencia, Spain 

Astrid Scharpantgen, Ministry of Health 
Luxembourg 

Barbara Schleicher, Austrian Health Institute 
Wien, Austria 

Nereo Segnan, Unit of cancer Epidemiology, Department of Oncology, CPO Piemonte  
and S. Giovanni Hospital 
Turin, Italy 

Brigitte Seradour, Association ARCADES 
Marseille, France 

Przemyslaw Seroczynski 
Poland 

Ferid Shannoun, Ministry of Health 
Luxembourg 

Miroslava Skovajsova, DTC Praha, Mamma Centrum 
Prague, Czech Republic 

Pär Sparen, Department of Medical Epidemiology and Biostatistics, Karolinska Institute 
Stockholm, Sweden 

Ofelia Suteu, Institutul Oncologic "I. Chiricuta" 
Cluj-Napoca, Romania 

Adam Svobodnik, Breast Screening Monitoring and Evaluation, Masaryk University Brno 
Brno, Czech Republic 

27

81 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ruth Tachezy 
Institute of Hematology and Blood Transfusion, Prague, Czech Republic 

Marios Televantos 
Archbishop Makarios III Hospital, Nicosia, Cyprus 

Mariano Tomatis 
CPO Piemonte, Turin, Italy 

Sven Törnberg 
Karolinska University Hospital, Cancer Screening Unit, Stockholm, Sweden 

Zdravka Valerianova 
Bulgarian National Cancer Registry, Sofia, Bulgaria 

Anne Vandenbroucke 
Centre de référence pour le dépistage du cancer du sein, Brussels, Belgium 

Pieter Vandenbulcke 
Flemish Public Health Administration, Brussels, Belgium 

Erik Vanlimbergen 
University Hospital Gasthuisberg, Leuven, Belgium 

László Vass 
Hospital of Pest County, Budapest, Hungary 

Piret Veerus 
National Institute for Health Development, Tallinn, Estonia 

My von Euler-Chelpin 
Institute of Public Health, University of Copenhagen, Denmark 

Clive Wells 
Queen Mary and Westfield College, St. Bartholomew's Hospital, London, United Kingdom 

Viaceslavas Zaksas,  
State Patient Fund under the Ministry of Health, Lithuania 

Marco Zappa 
Center for Study and Prevention of Cancer (CSPO), Florence, Italy 

Witold Zatonski 
Cancer Center & Institute of Oncology, Warsaw, Poland 

László Zsolt 
Szent János Hospital, Budapest, Hungary 

Raquel Zubizarreta 
General Direction of Public Health, Conselleria de Sanidad, Xunta de Galicia, Spain 

82 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AANNNNEEXX  22  

CCOOUUNNCCIILL  RREECCOOMMMMEENNDDAATTIIOONN  OOFF  22  DDEECCEEMMBBEERR  22000033  
OONN  CCAANNCCEERR  SSCCRREEEENNIINNGG  

31

83 
 
  
  
  
 
 84 
L 327/34

EN

Official Journal of the European Union

16.12.2003

COUNCIL RECOMMENDATION

of 2 December 2003

on cancer screening

(2003/878/EC)

THE COUNCIL OF THE EUROPEAN UNION,

Having regard to the Treaty establishing the European Com-
munity, and in particular Article 152(4), second subparagraph,
thereof,

Having regard to the proposal from the Commission,

Having regard to the opinion of the European Parliament,

Whereas:

Article 152 of
the Treaty provides that Community
to complement national policies and be
action is
directed towards improving public health, preventing
human illness and diseases, and obviating sources of
danger to human health. Such action shall cover the
fight against the major health scourges, by promoting
research into their causes, their transmission and their
prevention, as well as health information and education.
Community action in the field of public health shall fully
respect the responsibilities of the Member States for the
organisation and delivery of health services and medical
care.

Further development of cancer screening programmes
should be implemented in accordance with national law
and national and regional responsibilities for the organi-
sation and delivery of health services and medical care.

Cancer is a major disease and cause of death throughout
including the future Member States. An esti-
Europe,
mated number of 1 580 096 new cancer
cases,
excluding non-melanoma skin cancer, occurred in the
European Union in 1998. Of these, 1,4 % were cervical
cancers, 13 % breast cancers, 14 % colorectal cancers
and 9 % prostate cancers. Cervical and breast cancer
constituted 3 % and 29 %, respectively, of new cancers
in women. Prostate cancer constituted 17 % of new
cancers in men.

(1)

(2)

(3)

(4)

Principles for screening as a tool for the prevention of
chronic non-communicable diseases were published by
the World Health Organisation in 1968 and by the
Council of Europe in 1994. These two documents form,
together with the current best practice in each of the
cancer screening fields, the basis for the present recom-
mendations.

(10)

(5)

(6)

(7)

(8)

(9)

Additionally, these recommendations are based on the
‘Recommendations on cancer screening’ of the Advisory
Committee on Cancer Prevention together with the
experience gathered under the different actions sustained
under the Europe against Cancer programme where
European collaboration has helped, for example, high
quality cancer screening programmes to provide efficient
European guidelines of best practice and to protect the
population from poor quality screening.

Important factors which have to be assessed before a
population-wide
upon
include, inter alia, the frequency and interval of the appli-
cation of the screening test as well as other national or
regional epidemiological specificities.

implementation

decided

is

Screening allows detection of cancers at an early stage of
invasiveness or possibly even before they become inva-
sive. Some lesions can then be treated more effectively
and the patients can expect to be cured. The main indi-
cator for the effectiveness of screening is a decrease in
disease-specific mortality. As in the case of cervical
cancer, cancer precursors are detected, a reduction in
cervical cancer
incidence can be considered a very
helpful indicator.

Evidence exists concerning the efficacy of screening for
breast cancer and colorectal cancer, derived from rando-
mised trials, and for cervical cancer, derived from obser-
vational studies.

Screening is, however, the testing for diseases of people
for which no symptoms have been detected. In addition
to its beneficial effect on the disease-specific mortality,
screening can also have negative side effects for the
screened population. Healthcare providers should be
aware of all the potential benefits and risks of screening
for a given cancer site before embarking on new popula-
tion-based cancer screening programmes. Furthermore,
for the informed public of today, these benefits and risks
need to be presented in a way that allows individual citi-
zens
screening
programmes for themselves.

to decide on participation in the

legal,

social, medical,

Ethical,
and
economic aspects have to be considered before decisions
can be made on the implementation of cancer screening
programmes.

organisational

 8516.12.2003

EN

Official Journal of the European Union

L 327/35

(11) Due account should be taken of specific needs of
persons who may be at higher cancer risk for particular
reasons (e.g. biological, genetic,
lifestyle and environ-
mental, including occupational).

(21) Adequate human and financial resources should be avail-
able in order to assure the appropriate organisation and
quality control in all the Member States.

(12)

The public health benefits and cost efficiency of a
screening programme are achieved if the programme is
implemented systematically, covering the whole target
population and following best-practice guidelines.

(13)

The cost-effectiveness of cancer screening depends on
factors such as epidemiology, and healthcare
several
organisation and delivery.

(14)

(15)

Systematic implementation requires an organisation with
a call/recall system and with quality assurance at all
levels, and an effective and appropriate diagnostic, treat-
ment and after-care service following evidence-based
guidelines.

Centralised data systems, including a list of all categories
of persons to be targeted by the screening programme
and data on all screening tests, assessment and final diag-
noses,
screening
programmes.

organised

needed

run

are

to

(16) All procedures for collecting, storing, transmitting and
analysing data in the medical registers involved must be
in full compliance with the level of protection referred
to in Directive 95/46/EC of the European Parliament and
of the Council of 24 October 1995 on the protection of
individuals with regard to the processing of personal
data and on the free movement of such data (1), as well
as in full compliance with the relevant provisions of
Member States on the management and processing of
health data in accordance with Article 8 of the Directive.

(17) Quality screening includes analysis of the process and
outcome of the screening and rapid reporting of these
results to the population and screening providers.

(22) Action should be taken to ensure equal access

to
screening taking due account of the possible need to
target particular socioeconomic groups.

(23)

It is an ethical, legal and social prerequisite that cancer
screening should only be offered to fully informed
people with no symptoms if the screening is proved to
decrease disease-specific mortality,
if the benefits and
risks are well known, and if the cost-effectiveness of the
screening is acceptable.

(24)

The screening methods which presently meet these strict
prerequisites are listed in the Annex.

(25) No screening test other than those listed in the Annex is
scientifically justified to be offered to people with no
symptoms in an organised population-based programme
before it has been shown in randomised controlled trials
to decrease disease-specific mortality in particular.

(26)

The screening tests listed in the Annex can only be
offered on a population basis in organised screening
programmes with quality assurance at all levels, if good
information about benefits and risks, adequate resources
for screening, follow-up with complementary diagnostic
procedures and, if necessary, treatment of those with a
positive screening test are available.

(27)

The introduction of the recommended screening tests in
the Annex, which have demonstrated their efficacy,
should be seriously considered, the decision being based
on available professional expertise and priority-setting
for healthcare resources in each Member State.

(18)

This analysis is facilitated if the screening database can
be linked to cancer registries and mortality databases.

(28) Once there is evidence that a new screening test is effec-
tive, evaluation of modified tests may be possible using
other epidemiologically validated surrogate endpoints if
the predictive value of these endpoints is established.

(19) Adequate training of personnel is a prerequisite for high

quality screening.

(29)

(20)

Specific performance indicators have been established
for cancer screening tests. These should be monitored
regularly.

(1) OJ L 281, 23.11.1995, p. 31.

Screening methodologies are subject to ongoing develop-
ment. The application of recommended screening meth-
odologies should therefore be accompanied by simulta-
neous assessments of the quality, applicability and cost-
effectiveness of new methods if available epidemiological
data justify this. In fact, the ongoing work may lead to
new methods, which could ultimately replace or comple-
ment the tests listed in the Annex or be applicable to
other types of cancer,

 86L 327/36

EN

Official Journal of the European Union

16.12.2003

HEREBY RECOMMENDS THAT MEMBER STATES:

3. Monitoring

1. Implementation of cancer screening programmes

(a) offer

evidence-based

through a
cancer
systematic population-based approach with quality
assurance at all appropriate levels. The tests which
should be considered in this context are listed in the
Annex;

screening

(b) implement screening programmes in accordance with
European guidelines on best practice where they exist
and facilitate the further development of best practice
for high quality cancer screening programmes on a
national and, where appropriate, regional level;

(a) regularly monitor the process and outcome of organised
screening and report these results quickly to the public
and the personnel providing the screening;

(b) adhere to the standards defined by the European
Network of Cancer Registries in establishing and main-
taining the screening databases in full accordance with
relevant legislation on personal data protection;

(c) monitor the screening programmes at adequate inter-

vals.

4. Training

(c) ensure that

the people participating in a screening
programme are fully informed about the benefits and
risks;

adequately train personnel at all levels to ensure that they
are able to deliver high quality screening.

(d) ensure that adequate complementary diagnostic proce-
dures, treatment, psychological support and after-care
following evidence-based guidelines of
those with a
positive screening test are provided for;

(e) make available human and financial resources in order
to assure appropriate organisation and quality control;

(f) assess and take decisions on the implementation of a
cancer screening programme nationally or regionally
depending on the disease burden and the healthcare
resources available, the side effects and cost effects of
cancer screening, and experience from scientific trials
and pilot projects;

(g) set up a systematic call/recall system and quality assur-
ance at all appropriate levels, together with an effective
and appropriate diagnostic and treatment and after-care
service following evidence-based guidelines;

(h) ensure that due regard is paid to data protection legisla-
tion, particularly as it applies to personal health data,
prior to implementing cancer screening programmes.

2. Registration and management of screening data

(a) make available centralised data systems needed to run

organised screening programmes;

(b) ensure by appropriate means that all persons targeted
by the screening programme are invited, by means of a
call/recall system, to take part in the programme;

5. Compliance

(a) seek a high level of compliance, based on fully informed

consent, when organised screening is offered;

(b) take action to ensure equal access to screening taking
due account of the possible need to target particular
socioeconomic groups.

6. Introduction of novel screening tests taking into account

international research results

(a) implement new cancer screening tests in routine health-
care only after they have been evaluated in randomised
controlled trials;

(b) run trials,

in addition to those on screening-specific
parameters and mortality, on subsequent
treatment
procedures, clinical outcome, side effects, morbidity and
quality of life;

(c) assess level of evidence concerning effects of new
methods by pooling of trial results from representative
settings;

(d) consider the introduction into routine healthcare of
potentially promising new screening tests, which are
currently being evaluated in randomised controlled
trials, once the evidence is conclusive and other relevant
aspects, such as cost-effectiveness in the different health-
care systems, have been taken into account;

(c) collect, manage and evaluate data on all screening tests,

assessment and final diagnoses;

(d) collect, manage and evaluate the data in full accordance
with relevant legislation on personal data protection.

(e) consider the introduction into routine healthcare of
potentially promising new modifications of established
screening tests, once the effectiveness of the modifica-
tion has been successfully evaluated, possibly using
other epidemiologically validated surrogate endpoints.

 8716.12.2003

EN

Official Journal of the European Union

L 327/37

7. Implementation report and follow-up

report to the Commission on the implementation of this
Recommendation within three years of its adoption and
subsequently at the request of the Commission with a view
to contributing to the follow-up of this Recommendation at
Community level.

HEREBY INVITES THE COMMISSION:

2. To encourage cooperation between Member States

in
research and exchange of best practices as regards cancer
screening with a view to developing and evaluating new
screening methods or improving existing ones.

3. To support European research on cancer screening including
the development of new guidelines and the updating of
existing guidelines for cancer screening.

1. To report on the implementation of cancer

screening
programmes, on the basis of the information provided by
Member States, not later than the end of the fourth year
after the date of adoption of
to
consider the extent to which the proposed measures are
working effectively, and to consider the need for further
action.

this Recommendation,

Done at Brussels, 2 December 2003.

For the Council

The President

R. MARONI

 88L 327/38

EN

Official Journal of the European Union

16.12.2003

ANNEX

SCREENING TESTS WHICH FULFIL THE REQUIREMENTS OF THE RECOMMENDATION (*):

— pap smear screening for cervical cancer precursors starting not before the age of 20 and not later than the age of

30;

— mammography screening for breast cancer in women aged 50 to 69 in accordance with European guidelines on

quality assurance in mammography;

— faecal occult blood screening for colorectal cancer in men and women aged 50 to 74.

(*) The indicated age ranges are to be understood as maximum ranges; subject to national epidemiological evidence and prioritisation,

smaller age ranges may be appropriate.

 8990 
AANNNNEEXX  33  

QQUUEESSTTIIOONNNNAAIIRREE  OONN  IIMMPPLLEEMMEENNTTAATTIIOONN  OOFF  
CCAANNCCEERR  SSCCRREEEENNIINNGG  IINN  TTHHEE  EEUU  MMEEMMBBEERR  SSTTAATTEESS  

SSEENNTT  IINN  MMAAYY  22000077  
BBYY  TTHHEE    
EEUURROOPPEEAANN  CCOOMMMMIISSSSIIOONN,,  DDIIRREECCTTOORRAATTEE--GGEENNEERRAALL  
FFOORR  HHEEAALLTTHH  AANNDD  CCOONNSSUUMMEERRSS  
TTOO  TTHHEE  
EEUU  RREEPPRREESSEENNTTAATTIIOONNSS  OOFF  TTHHEE  2277  MMEEMMBBEERR  SSTTAATTEESS    

33

91 
 
  
  
  
  
  
 
92 
EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

I. 

Role of cancer screening in national cancer control programmes 

1.  Does your country have a national cancer control programme 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

2.  How is breast cancer screening anchored in your country's cancer control 

programme? 

(cid:134) not included 
(cid:134) included 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

3.  How is cervical cancer screening anchored in your country's cancer control 

programme? 

(cid:134) not included 
(cid:134) included 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

35

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EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

4.  How is colorectal cancer screening anchored in your country's cancer control 

programme? 

(cid:134) not included 
(cid:134) included 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

36 

94 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

II.  Questions for quantitative description of cancer screening in the Member 
States 

For comparability between countries, please report on the screening policy in your 
country at the end of the first 3-year reporting period, i.e., in 2006. If a relevant change in 
the situation has occurred in 2007, please comment on that separately, after answering 
the respective question based on the situation in 2006. 

Please provide statistical information based on the 12-month period January to December 
2005. If data is only available for an earlier period, please indicated that separately. If 
statistical data is available for 2006, please also report that data separately.  

Quantitative description of Target Groups 

In the Annex of Council Recommendation (2003/878/EC) three screening tests are listed 
to be offered to three different population groups at risk for cervical, breast and colorectal 
cancer. 

5.  Target cancers and target populations 

In 2006, did your country offer screening to the following target populations? 

Please indicate any differences between the Council recommendation and the age groups 
targeted for screening in your country. 

Please also indicate any differences in the screening test offered and/or in the disease 
targeted for screening (e.g. prostate or lung cancer screening). 

cervical cancer screening by offering the Pap test to women aged 20 and 

a) 
older? 

Policy in your country: (add extra text as necessary)   

b)  breast cancer screening by offering mammography to women aged 50 to 69, in 
accordance with European guidelines on quality assurance in mammography 
screening? 

Policy in your country: (add extra text as necessary)   

c) 

colorectal cancer screening by offering the faecal occult blood test to men and 
women aged 50 to 74? 

Policy in your country: (add extra text as necessary)   

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EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

d) 

screening for any other cancer not covered by 4 a) to 4 c) which your country 
offers to persons of average risk. 
Please give target population and screening test for each additionally targeted 
cancer 

Policy in your country: (add extra text as necessary)   

Quantitative description of organised screening programmes  

6.  In the year 2005, how many men and women of the respective population groups 
in your Member State which are targeted for screening  (see your answers to 
question 5 a) to 5 d)) were personally invited to attend the respective screening 
programmes? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006 please also provide these data. 

Quantitative description of compliance with organised screening programmes 

7.  In 2005, How many men and women of the respective target population  in your 
Member State to which the screening tests mentioned in 5 a) to 5 d) were offered 
by personal invitation, complied with and participated in screening programme? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006 please also provide these data. 

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Volume of organised screening programmes 

8.  In 2005, how many of the screening tests mentioned in 5 a) to 5 d) were  offered 
by personal invitation and performed for men and women of the respective 
population group in your Member State? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006 please also provide these data. 

Public costs of organised screening programmes 

9.  In 2005, how much has been paid by public authorities and/or health insurances 

for the screening tests mentioned in 5 a) to 5 d) offered within organised 
screening programmes? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006 please also provide these data. 

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

Quantitative description of opportunistic screening  

10. In 2005, how many men and women of the respective population group in your 
Member State are offered screening without systematic invitation for the tests 
mentioned in 5 a) to 5 d)? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006, please also provide these data. 

Volume of opportunistic screening  

11. In 2005, how many of the screening tests mentioned in 5 a) to 5 d) were provided 
for men and women of the respective population group in your Member State  
outside of an organised screening programme? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006, please also provide these data. 

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Public costs of opportunistic screening 

12. In 2005, how much has been paid by public authorities and/or health insurances 
for the screening tests mentioned in 5 a) to 5 d) outside of an organised screening 
programme ? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006, please also provide these data. 

Private costs of screening on demand 

13. In 2005, how much has been paid privately by individuals for the screening tests 

mentioned in 5 a) to 5 d) outside of an organised screening programme? 

Please provide data separately for a) to d) and broken down by men and women and 
by five-year age groups 

If data are available for 2006, please also provide these data. 

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EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

III.  Questions regarding details of national implementation of the Council 

recommendation on cancer screening 

Please tick the appropriate reply and/or give your comment where necessary 

Implementation of cancer screening programmes 

14. Is evidence-based cancer screening offered in your country through a systematic 
population-based approach with quality assurance at all appropriate levels, 
especially by performing the following tests: 

— pap smear screening for cervical cancer precursors starting not before the age of 20 
and not later than the age of 30; 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

— mammography screening for breast cancer in women aged 50 to 69 in accordance 
with European guidelines on quality assurance in mammography; 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

— faecal occult blood screening for colorectal cancer in men and women aged 50 to 74. 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 

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15. Is the breast cancer screening programme implemented in accordance with 
European guidelines for quality assurance in breast cancer screening and 
diagnosis – 4th edition; 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If not, please state the reasons: 

If yes, please provide further detail: (brief description of key aspects, information 
sources, etc.) 
........................................................................................................................................... 

16. Are people participating in a screening programme fully informed about related 

benefits and risks? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, how do you ensure their being informed? 

........................................................................................................................................... 

If not, what are the reasons for this situation? 
........................................................................................................................................... 

17. Are adequate complementary diagnostic procedures, treatment, psychological 

support and after-care following evidence-based guidelines provided for patients 
with a positive screening test? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If not, please state the reasons 
........................................................................................................................................... 

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If yes, please provide further detail: (brief description of key aspects, information 
sources, etc.) 
........................................................................................................................................... 

18. Are human and financial resources made available in order to assure 

appropriate organisation and quality control? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Are these resources satisfactory? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 
........................................................................................................................................... 

19. Before decisions on the implementation of a cancer screening programme have 
been taken on the national or regional level have the following factors been 
assessed? 

disease burden and the healthcare resources available 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 
........................................................................................................................................... 

side effects and cost effects of cancer screening 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide further detail: (brief description of key aspects, information sources, etc.) 
........................................................................................................................................... 

experience from scientific trials and pilot projects 

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(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, please provide further detail: (brief description of key aspects, information 
sources, etc.) 

........................................................................................................................................... 

If not, please state the reasons 
........................................................................................................................................... 

20. Has a systematic call/recall system and quality assurance been set up at all 

appropriate levels, together with an effective and appropriate diagnostic and 
treatment and after-care service following evidence-based guidelines? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, please provide further detail: (brief description of key aspects, information 
sources, etc.) 

........................................................................................................................................... 

If not, describe what were the reasons and what has been achieved 

............................... ........................................................................................................... 

21. Is due regard paid to European data protection legislation, particularly as it 
applies to personal health data, prior to implementing cancer screening 
programmes? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, please provide further detail: (brief description of key aspects, information 
sources, etc.) 
........................................................................................................................................... 

If not, please state the reasons 
........................................................................................................................................... 

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

Registration and management of screening data 

22. Are centralised data systems made available to run the organised screening 

programmes? 

(cid:134) yes 

If yes, please give examples of such data systems 
........................................................................................................................................... 

(cid:134) no 

If not, please state the reasons 

........................................................................................................................................... 
(cid:134) unknown/not applicable 

23. Are all persons targeted by the screening programme invited, by means of a 

call/recall system, to take part in the programme? 

(cid:134) yes 

If yes, please give examples of such data systems 

........................................................................................................................................... 

(cid:134) no 

If not, please state the reasons 

........................................................................................................................................... 
(cid:134) by other means (describe how): 

........................................................................................................................................... 
(cid:134) unknown/not applicable 

46 

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EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

24. Are data on all screening tests, assessment and final diagnoses collected, 

managed and evaluated? 

(cid:134) yes 

If yes, please provide additional information, e.g., key aspects, sources of information, 
etc. 

If only partially, please add additional explanatory comment 

........................................................................................................................................... 

(cid:134) no 

If not, please state the reasons 

........................................................................................................................................... 

(cid:134) unknown/not applicable 

25. Are data collected, managed and evaluated in full accordance with relevant 

European legislation on personal data protection? 

(cid:134) yes 

If yes, please provide additional information, e.g., key aspects, sources of information, 
etc. 

(cid:134) no 

If not, please explain what are the obstacles 

........................................................................................................................................... 

(cid:134) unknown/not applicable 

47

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

Monitoring 

26. Is the process and outcome of organised screening regularly monitored by an 

independent peer review? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide additional information, e.g., key aspects, sources of information, etc. 

and are these results reported quickly to the public and the personnel providing the 
screening 

(cid:134) yes 

If yes, please provide additional information, e.g., key aspects, sources of 
information, etc. 

(cid:134) no 

If not, please state the reasons 

.........................................................................................................................................
.. 

(cid:134) unknown/not applicable 

27. Does your country adhere to the standards defined by the European Network of 
Cancer Registries in establishing and maintaining the screening databases in full 
accordance with relevant European legislation on personal data protection? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

Please provide additional information, e.g., key aspects, sources of information, etc. 

48 

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

28. Are screening programmes monitored by national cancer registries at adequate 

intervals? 

(cid:134) yes 

If yes, please provide additional information, e.g., key aspects, sources of 
information, etc. 

(cid:134) no 

If not, please state the reasons and describe what should be the level attained 

.........................................................................................................................................
.. 

(cid:134) unknown/not applicable 

Training 

29. Is personnel adequately trained at all levels to ensure that they are able to 

deliver high quality screening 

(cid:134) yes 

Please describe how this is achieved 
........................................................................................................................................... 

(cid:134) no 

Please state the reasons 

........................................................................................................................................... 

(cid:134) unknown/not applicable 

49

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

Compliance 

30. When organised screening is offered is a high level of compliance treated as a 

priority, based on fully informed consent 

(cid:134) yes 

Please describe how this is achieved 

........................................................................................................................................... 

(cid:134) no 

If not, please state the reasons 

........................................................................................................................................... 

(cid:134) unknown/not applicable 

31. Is any action taken to ensure equal access to screening taking due account of the 

possible need to target particular socioeconomic groups? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, please give examples of undertaken actions 

........................................................................................................................................... 

50 

108 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

Introduction of novel screening tests taking into account international research 
results 

32. Are new cancer screening tests in routine healthcare implemented only after 

having been evaluated in randomised controlled trials? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If not, please describe the measures which are undertaken 
........................................................................................................................................... 

33. Does your country run trials, in addition to those on screening-specific 

parameters and mortality, on subsequent treatment procedures, clinical 
outcome, side effects, morbidity and quality of life? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

on which of the following: 

(cid:134) subsequent treatment procedures 
(cid:134) clinical outcome 
(cid:134) side effects 
(cid:134) morbidity 
(cid:134) quality of life 

34. Is the level of evidence concerning the effects of new methods assessed by 

pooling of trial results from representative settings; 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If yes, give some examples 

........................................................................................................................................... 

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HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL 

35. Does your country consider to introduce or has it introduced potentially 
promising new screening tests, which are currently being evaluated in 
randomised controlled trials into routine healthcare, once the evidence is 
conclusive and after having taken into account other relevant aspects, such as 
cost-effectiveness in the different healthcare systems  

(cid:134) yes 

If yes, please provide additional details, e.g. key apects, sources of information, etc.  

(cid:134) no 

If not, please state the reasons. 

........................................................................................................................................... 

(cid:134) unknown/not applicable 

36. Does your country consider to introduce potentially promising new 

modifications of established screening tests, once the effectiveness of the 
modification has been successfully evaluated, into routine healthcare, possibly 
using other epidemiologically validated surrogate endpoints? 

(cid:134) yes 
(cid:134) no 
(cid:134) unknown/not applicable 

If not, please state the reasons. 

........................................................................................................................................... 

52 

110 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AANNNNEEXX  44  

NNOONN--EEXXHHAAUUSSTTIIVVEE  LLIISSTT  OOFF  RREELLEEVVAANNTT  AACCTTIIOONNSS  
TTAAKKEENN  BBYY  IINNDDIIVVIIDDUUAALL  MMEEMMBBEERR  SSTTAATTEESS  
SSIINNCCEE  22000033  

TTHHEE  YYEEAARR  IINN  WWHHIICCHH  TTHHEE  
CCOOUUNNCCIILL  RREECCOOMMMMEENNDDAATTIIOONN  OONN  CCAANNCCEERR  SSCCRREEEENNIINNGG  
WWAASS  AADDOOPPTTEEDD  

  53

111 
  
  
  
  
  
 
Annex 4:  Non-exhaustive list of relevant actions taken by individual Member States since 2003, the year in which the Council 

Recommendation on Cancer Screening was adopted 

No.  Country 

Breast cancer screening 

Cervical cancer screening 

Colorectal cancer screening 

Screening in general 

Optional screening colonoscopy 
(10-year interval) added to 
catalogue of non-population-based 
screening examinations (in addition 
to previously offered annual or 
biennial FOBT) 
Initiatives are being taken at the 
regional and loco-regional level to 
promote implementation of 
colorectal cancer screening 
according to the European 
recommendations 
Colorectal cancer screening 
programme is being dealt with in 
2008 in preparations for National 
Cancer Control Strategy 2009-2019 
Population-based colorectal cancer 
screening programme adopted in 
2007. Invitation of 50-yr.-old men 
and women to FOBT screening, and 
55-year-old men and women to co-
lonoscopy screening will begin in 
2008 

1 

Austria 

Planning and implementation of 
population-based breast cancer 
screening programmes based on 
mammography 

Testing of invitation systems for 
annual PAP smear 

Initiatives are being taken at the 
regional and loco-regional level to 
promote implementation of cervical 
cancer screening according to the 
European recommendations 

Cervical cancer screening 
programme is being dealt with in 
2008 in preparations for National 
Cancer Control Strategy 2009-2019  

Testing of invitation systems for 
cervical cancer screening 

Breast cancer screening programme 
is being dealt with in 2008 in 
preparations for National Cancer 
Control Strategy 2009-2019 
Recent initiatives in 2007 to fulfil 
standards and recommendations of 
EU guidelines (upgrading 
computerised documentation and 
monitoring system, and expert 
consultations to prepare 
programme certification). 
Rollout of population-based breast 
screening programme completed in 
Greek-Cypriot part of country. 
Conversion of non-population-
based, to population-based breast 
cancer screening programme 
started in 2007 (rollout of personal 
invitation to initial screening and 
personal re-invitation to subsequent 
screening) 

2 

Belgium 

3 

Bulgaria 

4 

Cyprus 

Czech 
Republic 

5 

6 

54

National Cancer Control Strategy 
2009-2019 is being developed in 
2008 

112 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No.  Country 

Breast cancer screening 

Cervical cancer screening 

Colorectal cancer screening 

Screening in general 

7 

Denmark 

8 

9 

10 

Estonia 

11 

Finland 

12 

France 

As of 31 December 2007 a 
nationwide screening 
programme based on 2-yearly 
mammography for women aged 
50 to 69 years has been 
established in all five regions of 
the country which are 
responsible for the secondary 
health sector. 
National guidelines for breast 
cancer screening are being drafted 
in 2008. 

National monitoring of the breast 
cancer screening programme is in 
preparation in 2008. 
Rollout of nationwide population-
based breast cancer screening 
completed. 

Start of extension of upper age limit 
for invitation to population-based 
breast cancer screening from 59 or 
64, to 69 years in all regions of the 
country. Extension to age 69 will be 
phased in gradually over the 
coming years. 
Revised organisation and 
procedures and eligible age range 
(50-74 years) of nationwide, 
population-based breast cancer 
screening programme 

As of 31 December 2007 the 
upper age limit for the 
population-based nationwide 
screening programme has been 
extended from 59 to 65 years. 

An FOBT-based pilot study of 
colorectal cancer screening was 
performed 2005-2006.  

A national cervical cancer screening 
registry is being established in 2008 

National monitoring of the cervical 
cancer screening programme is in 
preparation in 2008 
Conversion of non-population-
based cervical cancer screening to 
a population-based programme 
initiated and completed. 

An ongoing HTA was initiated in 
2007 to analyze the pilot results 
and international results and to 
inform an impending 
recommendation of the National 
Board of Health on introduction 
of a nationwide colorectal 
cancer screening programme. 

Start of nationwide, population-
based colorectal cancer screening 
programme using FOBT and 
according to a randomised public 
health intervention design. Rollout 
is currently ongoing. 

Population-based pilot programmes 
of cervical cancer screening 
established in four regions. 

Nationwide population-based 
programme for colorectal cancer 
screening based on FOBT initiated. 
Rollout is currently ongoing. 

  55 

113 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No.  Country 
13  Germany 

14  Greece 

15  Hungary 

16 

Ireland 

17 

Italy 

Breast cancer screening 
Adoption and initiation of rollout of 
nationwide population-based breast 
cancer screening programme based 
on EU guidelines 
Introduction of pop.-based cervical 
cancer screening foreseen in 
National Cancer Plan 2008-2012 
which is under public consultation. 

Completion of rollout of nationwide 
population-based mammography 
screening. 
Rollout of the population-based 
breast screening programme to the 
southern and western regions of 
the country. 
Rollout of population-based breast 
screening programmes expanded 
continuously. By 2006, 77% of the 
target population in Italy resided in 
areas in which population-based 
breast screening programmes were 
active. In 2007 in all Italian regions, 
at least one pilot population-based 
breast screening programme was 
implemented. 

18 

19 

56

Cervical cancer screening 
Pilot projects to improve quality 
and effectiveness of cervical cancer 
screening initiated. 

Colorectal cancer screening 
Nationwide campaigns to promote 
non-population-based colonoscopy 
screening for colorectal cancer 

Screening in general 

Introduction of pop.-based cervical 
cancer screening foreseen in 
National Cancer Plan 2008-2012 
which is under public consultation 

Introduction of pop.-based cervical 
cancer screening foreseen in 
National Cancer Plan 2008-2012 
which is under public consultation 

National Cancer Plan 2008-2012 
has been developed and is under 
public consultation in 2008. 
Includes provisions designed to 
follow Council Recommendation 

Planning and preparation for 2008 
introduction of nationwide 
population-based cervical screening 
programme 
Rollout of population-based cervical 
cancer screening programmes 
expanded continuously. By 2006 
approximately 70% of the Italian 
target population resided in areas 
served by active cervical screening 
programmes. 

Piloting of population-based 
colorectal cancer screening using 
FOBT. 
Appointment of expert committee 
to advise the national authorities on 
colorectal cancer screening 

Rollout of population-based 
colorectal cancer screening 
programmes expanded 
continuously. By 2006 
approximately 45% of the Italian 
target population resided in areas 
served by active population-based 
colorectal cancer screening 
programmes. 

In 2004, the National Parliament 
allocated 52 million € to address 
the uneven distribution of cancer 
screening services in Italy 

Subsequently, the National 
Prevention Plan 2005-2007 was 
established and implementation has 
been coordinated by national 
authorities promoting monitoring, 
evaluation and networking between 
local and regional breast, cervical 
and colorectal cancer screening 
programmes. 
In 2005 the National Centre for 
Screening Monitoring, linked with 
the Centre of Disease Control 
(CCM) of the Ministry of Health was 
established. 

114 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No.  Country 
20 

Latvia 

21 

22 

Lithuania 

23 

24  Malta 

25 

The 
Netherlands

Breast cancer screening 
Nationwide non-population-based 
breast cancer screening has been 
established in 2005 
Actions for transition to population-
based breast cancer screening 
programme with  2-yearly 
mammography screening for 
women aged 50-69have been 
incorporated into National Cancer 
Control Programme which is under 
development in 2008. 
Nationwide non-population-based 
breast cancer screening established 

Methods developed for population-
based monitoring of breast cancer 
screening. 
In 2007, national authorities 
decided to begin implementation of 
a population-based breast 
screening programme. Three-yearly 
mammography, age 50-59, 
extension later to age 69) will be 
provided in 2008. 
Upper age limit of invitation to 
population-based breast cancer 
screening extended from 69 to 75 
years 

26 

Central coordination of nationwide 
transition of breast cancer 
screening programme from 
conventional to digital 
mammography 

Cervical cancer screening 
Nationwide non-population-based 
cervical screening has been 
established in  2005 
Actions for transition to population-
based cervix cancer screening 
programme have been incorporated 
into National Cancer Control 
Programme which is under 
development in 2008. 

Colorectal cancer screening 
Nationwide non-population-based 
colorectal cancer screening has 
been established in 2005 
Actions for transition to population-
based colorectal cancer screening 
programme have been incorporated 
into National Cancer Control 
Programme which is under 
development in 2008. 

Screening in general 
Cabinet decision in December 2006 
to develop a National Cancer 
Control Programme and Action Plan  
2008 final preparations for adoption 
of National Cancer Control 
Programme and Action Plan 
(expected date of adoption: Oct. 
2008, expected date to take effect: 
1 Jan 2009 

Nationwide non-population-based 
cervical cancer screening 
established. 
Methods developed for population-
based monitoring of cervical cancer 
screening. 

Development of national guidelines 
for implementation of HPV testing 
in nationwide population-based 
cervical cancer screening 
programme 

Pilot studies employing FOBT and 
flexible sigmoidoscopy as screening 
tests for colorectal cancer have 
been conducted. The results and 
experience will be taken into 
account in the decision-making 
process on nationwide programme 
implementation. 

  57 

115 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Breast cancer screening 
Nationwide population-based 
programme for breast cancer 
screening initiated (rollout currently 
ongoing). 

Cervical cancer screening 
Nationwide population-based 
programme for cervical cancer 
screening initiated (rollout currently 
ongoing). 

Colorectal cancer screening  Screening in general 
Colorectal cancer screening based 
on colonoscopy piloted. 

Invitation system for population-
based cervical cancer screening 
introduced in the central region of 
the country. Nationwide rollout to 
begin in 2008. 

Screening Executive Agency 
initiated planning in 2007 for 
nationwide, population-based 
cervical screening programme (5-
yearly cervical cytology for women 
age 25-64). 
Completion of a regional pilot of 
population-based cervical cancer 
screening 

Coverage of nationwide population-
based breast cancer screening 
increased by extending screening 
to more regions and areas. 

Screening Executive Agency 
initiated planning in 2007 for 
nationwide, population-based 
colorectal cancer screening 
programme (2-yearly FOBT for men 
and women age 50-74). 

National guidelines including quality 
control of mammography 
equipment based on the European 
guidelines have been issued for the 
nationwide, non-population-based 
breast cancer screening 
programme. 
Planning and organisational, 
professional and scientific 
preparation of nationwide 
population-based breast cancer 
screening programme. Rollout 
beginning in the first half of 2008. 

Nationwide population-based pro-
gramme for colorectal cancer 
screening initiated (rollout currently 
ongoing).. 
Planning and preparation of 
population-based colorectal cancer 
screening completed in 2007. 
Screening will begin in the central 
region of Portugal in 2008. 

Screening Executive Agency 
initiated planning in 2007 for 
nationwide, population-based 
colorectal cancer screening 
programme (2-yearly FOBT for men 
and women age 50-74). 

A nationwide, non-population-
based colorectal cancer screening 
programme is currently in the 
planning phase. 

Planning and organisational, 
professional and scientific 
preparation of nationwide 
population-based colorectal cancer 
screening programme. Rollout 
beginning in the first half of 2008. 

Executive Agency for Screening, 
establishment at Ministry of Health 
in 2007 

No.  Country 
27  Poland 

28 

29  Portugal 

30  Romania 

31 

32 

Slovak 
Republic 

33 

Slovenia 

58

116 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No.  Country 
34 

Spain 

35 

Sweden 

36  United 

Kingdom 

Breast cancer screening 

Revised national mammography 
screening recommendations (full 
age range 40-74 years now 
recommended without exception). 

Upper age limit of population-
based invitation to breast cancer 
screening extended from 64 to 70 
years. Women over 70 years can 
request invitation. 

Cervical cancer screening 
Population-based cervical cancer 
screening programmes established 
in two regions. 
Comprehensive auditing of 
population-based cervical cancer 
screening services initiated. 

Establishment of national breast 
screening network for exchange of 
information and experience 

Colorectal cancer screening  Screening in general 
Pilot programmes for colorectal 
cancer screening established in 
three regions. 
Regional population-based 
colorectal cancer screening 
programme planned in Stockholm 
region. Programme start in January 
2008. 
Conventional cytology replaced by 
liquid-based cytology in the 
national cervical cancer screening 
programme. 

Population-based colorectal cancer 
screening using the FOBT has been 
piloted and subsequently rolled out 
in England and Scotland. FOBT 
screening programme has been 
adopted in Wales, with final 
decision in Northern Ireland 
pending. 

  59 

117 
 
 
 
 
 
 
 
 
118 
AANNNNEEXX  55  

QQUUAALLIITTAATTIIVVEE  FFEEEEDDBBAACCKK  FFRROOMM  TTHHEE  MMEEMMBBEERR  SSTTAATTEESS  
OONN  IIMMPPLLEEMMEENNTTAATTIIOONN  OOFF  TTHHEE  CCOOUUNNCCIILL  
RREECCOOMMMMEENNDDAATTIIOONN  

119  
  
  
  
 
Annex 5:    Cancer Screening in the European Union - Qualitative Description

1. Implementation of cancer screening programmes - key aspects

 1a1 

1a2

1a3

1b

1c

1d

1e-q1

1e-q2

1f1

1f2

1f3

1g

1h

2. Screening data registration & 
management
2b
2c

2d

2a

3. Screening programmes 
monitoring 
3a2
3b

3c

3a1

Council
Recommendations

Population-based 
screening with QA at 
all appropriate levels
using

EU 
breast 
guide-
lines 

Fully 
inform-
ed

Ade-
quate 
care for

Human & finan. 
resources for 
organisation
& QC

Implementation
decisions
based on 

Call/ 
Recall, 
effective

Data 
protec-
tion

Central-
ised data 
systems

Call/ recall 
system 

Collect, 
manage & 
evaluate 
data

Data 
handling in 
full accor-
dance

Regular monitoring of 
process & outcome of 
organised screening

ENCR 
screening 
data base 
standards 
& EU laws

National 
cancer 
registries 
monitor 
programme

 EC
 Questionnaire

Austria
Belgium 
Bulgaria
Cyprus
Czech Rep
Denmark
Estonia 
Finland
France
Germany
Greece
Hungary
Ireland 
Italy 
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovakia
Slovenia
Spain 
Sweden
UK
Y (subtot.) 
N (subtot.)
N*
MV (subtot.)
Total

14a
14b
PAP Mx

14c

15

16

FOBT Follow-

ed

Y
Y

Y
Y

Y

Y
Y
N#
Y

Y
N
Y
Y
N
MV
Y 
N

Y
N
Y
Y
Y
15
6

1
22

Y
Y#

Y
Y

Y

Y
Y
Y
Y

Y
Y
Y
Y
N*
Y
Y
Y

Y
Y
Y
MV
Y
20

1
1
22

N*
N

N
N

Y

N#
N#

Y

N#
Y
N#
N#
Y**
Y#
Y

N#
Y
N
Y
Y 
11
9
2

22

Y#
Y

Y
Y

Y

Y
Y

Y

N#
Y
Y
N#
Y**
Y#
Y

N#
N#
Y**
Y
Y#
17
3
1
1
22

N#
N#

N
N#

N

Y
N#

Y#

N#
N*
N#
N#
N
N#
N#

N#
N#
Y#
N
Y#
6
13
2
1
22

17
Screen-
pos-
tives

18a 
 Provid-
ed

18b
 Ade-
quate

19a
Disease 
burden & 
health 
resources

19b
Side 
effects/ 
cost- 
effectvn.

19c
Sci. trials/ 
pilots

20
 Diagn. 
treatm. 
After care

Y
Y#

Y
Y

Y

N*
Y
Y#
Y

Y
Y
Y
Y
Y
Y
Y
Y

Y#
Y#
Y
Y
Y
21

1

22

N
Y#

Y
Y

Y  

Y
Y
Y#
MV

Y
N
N
Y
Y
Y
Y
Y

Y
Y
N*
Y
Y
18
2
1
1
22

N
Y#

Y
N

N

Y
Y
MV
MV

MV
N
N
N
N
Y
Y
Y#

N
N
N*
Y
Y
9
9
1
3
22

Y
Y#

Y
Y

Y

Y
Y
MV
Y

N*
N
Y
Y
Y
N
Y
Y

Y
Y
Y
Y
Y
18
2
1
1
22

Y
Y#

MV
Y

Y

Y
Y
MV
Y

N*
N
N
N
N*
N
N
Y

N
Y
Y
N*
Y
11
6
3
2
22

Y
Y#

N
Y

Y

Y
Y
MV
Y

N*
N
Y
N
Y
N
Y
N*

Y
Y
Y
Y
Y
15
4
2
1
22

Y
Y#

Y
Y

Y

Y
Y# 
Y# 
Y

Y
N
Y#
Y
N
Y
Y
Y

N
Y
Y
Y
Y
19
3

22

21

Y
Y

Y
Y

Y

Y
Y
Y#
Y

Y
Y
Y
Y
Y
NA
Y
Y

Y
Y
Y
Y
Y
21

1

22

22
For running 
program-
mes

23
To invite all 
targeted 
persons

24
On test, 
assess-
ment, 
diagnoses

25
With data 
protection 
legislation

26a
By inde-
pendent 
peer  
review

26b
With quick 
reports to 
public and 
staff

27
On data 
protection 
fully 
followed

28
At ade-
quate 
intervals

Y
Y

Y#
Y

N

Y
Y
Y
Y

Y
Y#
Y#
N
N* 
Y
Y
Y

N
Y
Y
Y
Y
18
3
1

22

Y
Y

Y
Y

Y

Y
Y#
Y#
Y

Y
N*
N
Y
N*
Y
Y#
Y

N
Y
Y
Y
Y
18
2
2

22

Y
Y

Y#
Y

Y

Y
Y#
Y#
Y

Y
Y#
Y
Y
N
Y
Y
Y

N
Y
Y
Y
Y
20
2

22

Y
Y

Y
Y

Y

Y
Y#
Y#
Y

Y
MV
Y
Y
N* 
Y
Y
Y

Y
Y
Y
Y
Y
20

1
1
22

N
Y#

N
N

Y
Y

Y#
Y#
Y

N*
MV
Y#
N
N*
Y
Y
N

N*
Y
Y
N
Y
12
6
3
1
22

Y
Y#

MV
MV

Y
Y

Y#  
y# 
Y

MV
MV
Y
Y
N*
N
Y
N

MV
Y
Y
MV
Y
13
2
1
6
22

N*
Y#

Y
Y

N*
Y

Y
Y#
MV

N*
N
Y#
N#
N* 
MV
Y
Y

Y
Y
Y
Y
Y
14
2
4
2
22

N
N

N
Y

N
N*

Y#
Y#
N

Y
MV
Y
N*
N* 
N
Y
N

Y
Y
N
N
Y
10
8
3
1
22

  Code: Y( Yes),    N (No), N* (Unknown/ not applicable), MV: Missing Value
**Data from other item in EC questionnaire, or from other source     

  Source (unless otherwise indicated): Survey DG SANCO 2007   
 #See footnotes on next to last page of Annex 5.

1204.Train-
ing
4

Personnel 
adequately 
trained at
all levels

Council
Recommendations

Annex 5 cont'd:   Cancer Screening in the European Union - Qualitatitve Description

5. Compliance

6. Introduction of novel screening tests taking into account international research results.

5a

5b

6a

6b1

6b2

6b3

6b4

6b5

6b6

6c

6d

6e

Priority for 
high com- 
pliance to 
organized 
screening

Action 
taken for 
equal 
access to 
screening

New 
screening 
tests only 
imple-
mented

Trials run on any of the following subjects
(in addition to screening-specific parameters and mortality):
 treatment procedures, clinical outcomes, side effects,
morbidity, quality of life

Level of 
evidence for 
new tests

 EC
 Questionnaire

29
To ensure 
delivery of 
high quality 
screening

30
Based on 
fully 
informed 
consent

31
Account-
ing for 
special 
socio-

32
After evalu-
ation in 
RCTs

33
Any of
speci-
fied topics

33a
Treatment 
procedures

33b
Clinical out-
comes

33c
Side-
effects

33d

33e

34

Morbidity Quality of life Assessed by 

pooling 
representa-
tive trials

Austria
Belgium 
Bulgaria
Cyprus
Czech Rep
Denmark
Estonia 
Finland
France
Germany
Greece
Hungary
Ireland 
Italy 
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovakia
Slovenia
Spain 
Sweden
UK
Y (subtot.) 
N (subtot.)
N*
MV (subtot.)
Total

Y
Y

Y
Y

Y

Y
Y
Y#
Y

Y
Y
Y
Y
N* 
Y
Y
N

Y
Y
Y
Y
Y
20
1
1

22

Y
Y

Y
Y

Y

Y
Y
Y#
Y

Y
MV
Y
Y
N*
Y
Y
Y

Y
Y
Y
Y
Y
20

1
1
22

Y
Y#

Y
N

Y

Y
Y
Y#
Y

Y
Y
N*
Y
N*
Y
Y
Y

Y
Y
Y
N
Y
18
2
2

22

N
Y /N*

N
Y

Y

Y
Y
Y#
Y

Y
Y
N*
Y
N*
Y
N*
N*

Y
Y
Y
Y
Y
17
2
3

22

MV
N

N
Y

N*

Y
Y#
Y
N

Y
MV
N*
N
Y
Y
Y
N*

Y
Y
Y
Y
Y
14
4
2
2
22

MV
N 

MV
Y

MV

Y
Y
Y
N*

Y
MV
MV
MV
Y
Y
Y
MV

MV
Y
Y
Y
Y
12

1
9
22

MV
MV

MV
Y

MV

Y
Y
Y
N*

Y
MV
MV
MV
Y
Y
Y
MV

MV
Y
Y
Y
N
11
1
1
9
22

MV
MV

MV
Y

MV

Y
Y
Y
N*

Y
MV
MV
MV
Y
Y
MV
MV

MV
N 
Y
Y
Y
10
1
1
10
22

MV
MV

MV
Y

MV

Y
Y
Y
N*

MV
MV
MV
MV
Y
Y
Y
MV

MV
N 
Y
Y
Y
10
1
1
10
22

MV
MV

MV
Y

MV

MV
Y
Y
N*

MV
MV
MV
MV
Y
Y
MV
MV

MV
Y
Y
Y
Y
9

1
12
22

MV
Y

N
N

N*

N*
Y
Y
N*

MV
MV
N*
N
N*
Y
N
N*

Y
Y
Y
Y
Y
9
4
6
3
22

  Code: Y( Yes),    N (No), N* (Unknown/ not applicable), MV: Missing Value
**Data from other item in EC questionnaire, or from other source     

  Source (unless otherwise indicated): Survey DG SANCO 2007   
 #See footnotes on next to last page of Annex 5.

New 
potential 
tests 
introduced or 
under

Test 
modifica-
tions consi-
dered after 
eval. of effec-

35
Consider 
based on 
RTC, cost-
effect., etc.

ti

36
In routine 
health care, 
possibly 
using valida-

Y
Y

N
Y

N*

Y
Y
Y#
N*

Y
N
MV#
N
N
Y
N
Y

N*
N
Y
Y
Y
12
6
4

22

Y
N

N
Y

N*

N*
Y
Y#
Y

MV#
N
MV#
N
N#
Y
N
Y

N*
Y
Y
Y
Y
12
6
3
1
22

121Annex 5 cnt'd:    Cancer Screening in the European Union - Qualitatitve Description

Country

Column

#  Footnotes by country:

Austria 

Belgium

Cyprus

1a2

1a3

1a3

1a3

1a3

1c-1g

3a1-3b 

5b-6a
2a, 3c

Czech Republic 1a3

France
Germany

1a1
1a1, 1a3

Changed to yes (plausibility check) due to pilot projects

Changed to no (plausibility check) because no invitation data available, invitations planned

Non.population-based programme including colonoscopy

Changed to no (plausibility check) because no invitation data available

Non-population-based programme

Only implemented in some regions

Only implemented in some regions

Only implemented in some regions

Health monitoirng unit of MOH will monitor the programme when the current upgrading of the
computerized documentation system is completed. Population registry provides invitation data.

Changed to no (plausibilty check) non-pop.-based colonocopy screening, individual data collected since 
2006, no men personally invited

Pop.-based programmes only in some regions

Changed to no .Non-population-based cervical and CRC screening programmes (call and recall only for Mx 
screening)

1g, 2b

2c

2d-3a2 
3c

3c

6b1
1a1, 1a3

Call and recall only for breast cancer screening.

For Mx and CRC screening. In 2008 evaluation and feetback for cervical screening will be provided 

Currently for breast and colorectal cancer, for cervical cancer planned in 2008

Cancer registries participate in regular ongoing evaluation of Mammography screening 

In individual studies for other screening activities, colonoscopy and skin cancer.

Exceptions allowed 
Pop.-based pilot programmes were running in 1990s and early in millenium. Current status unknown

16, 33, 34

Only items unequivocally confirmed, all other confirmations refer to expected cancer control programme 

1a3

1a1
1a1

1a2

1a1-3

2a,2c 

6d

6e

1g 

2a,3a1,3b 
1a1, 1a3
1a1, 1a3

1a3

3b 

1a1

1a2

1a3
6e

Model programme

Regional until introduction of national programme in 2008

Non-population-based screening in areas in which pop.-based programme is not yet implemented

Not yet implemented nationwide

Non-population-based programmes 

Partly

Considering enhancing screening due to limited financial resources

Not included (limited financial resources)

Partly

Partly

Changed to no (plausibility check) because no personal invitations issued

Non-population-based programmes

Biennial FOBT offered to patients in individual cancer control programme who refuse colonoscopy

Under discussion

Non-programme Pap screening is free of charge in public sector, self referral or by doctor

Pop.-based programme to start 2008. High risk, non-prog., free public screening (HRT, fam. risk)

High risk, non-prog. free screening in public sector (FAP, 1st deg. Relative with FAP)

Malta is still in proces on gaining further experience on conventional methods

Greece

Hungary

Ireland

Latvia

Lithuania 

Luxemburg 

Malta

Poland

1a1, 1a2

First invitations sent 2007

1a3

2b 

1a3

1e-q2

No FOBT screening, but pop.-based colonoscopy screening is provided for average risk population, 

and non-population-based screening offered to medium and high-risk groups

>1/2 of breast and 1/3 of cervical target pop.invited:  CRC part of target pop. tested.

Implenentation in phases from 2007-2013 Check if started and if pop.-based

Regional resources limited due to regional financing but adequte technical and scientific quality

Portugal

Slovak Repub

1a1, 1a2, 1a3 Changed to no .Non-pop-based national screening programmes without personal invitation

Slovenia  

Spain

Slovenia  

Spain

UK 

1d

1a2

1a3

1a3

1a2

1a3

1a3

1a2

1a3 

For cervical cancer screening

Start of pop.-based national programme in  2008. 

Start of pop.-based national programme in January 2008.

Loco-regional pilot programmes

Start of pop.-based national programme in 2008 (ECN). 

Start of pop.-based national programme 2008 (ECN). 

Loco-regional pilot programmes

Breast cancer screening: Note different age group; 50-70 invited  3 yearly, 70+ on request.

Note different age group; roll out for age group 50-69 from 6/2006 to 12/2009 in England

122Annex 5 cont'd:   Cancer Screening in the European Union - Qualitatitve Description

Items in qualitative part of DG SANCO survey questionnaire 2007

14a PAP: PAP smear begin at 20-30 yrs

14b Mx: MX 50-69 yrs

14c FOBT: FOBT 50-74 yrs 

15

16
17

Followed: Breast  screen Pgm: Breast screening programme implemented according to - 4th ed of EU breast 
guidelines?
People fully informed about related benefits and risks?
Screen-postives: Adequate complementary procedures, treatment, psychological support and after-care following 
evidence-based guidelines provided for patients with a positive screening test?

18a  Provided: Are human and financial resources made available in order to assure appropriate organisation and quality 

control

18b Adequate: Are these resources satisfactory

19a Disease burden & health resources: Disease burden and the healthcare resources available

19b Side effects/ cost- effectiveness: Side effects and cost effects of cancer screening

19c Scientific trials/ pilots: Experience from scientific trials and pilot projects
20 Diagnosis, treatment. Aftercare: Has a systemaic call/recall system and QA been set up at all appropriate levels, 

together with an effective and appropriate diagNstic and treatment and after-care service following evidence-based 
guidelines?

Is due regard paid to European data protection legislation, particularly as it applies to personal health data, prior to 
implementing cancer screening programmes?
For running programmes: Are centralised data systems made available to run the organised screening programmes?

To invite all targeted persons: Are all persons targeted by the screening programme invited, by means of a call/recall 
system, to take part in the programme?

22

23

24 On test, assessm, diagn. Are data on all screening tests, assessment and final diagnoses collected, managed and 

evaluated?

25 With data protection legislation: Are data collected, managed and evaluated in full accordance with relevant European 

legislation on personal data protection?

26a By independent peer  review: Is the process and outcome of organised screening regularly monitored by an independent 

peer review?

26b With quick reports to public and staff: Are these results reported quickly to the public and the personnel providing the 

screening?

27 On data protection fully followed: Does your contry adhere to the standards defined by the European Network of Cancer 
Registries in establishing and maintaining the screening datbases in full accordance ith relevant European legislation on 
personal data protection

28

29

30

33

At adequate intervals: Are screening programmes monitored by national cancer registries at adequate interval?

To ensure delivery of high quality screening: Is personnel adequately trained at all levels to ensure that they are able to 
deliver high quality screening?
Based on fully informed consent
When organised screening is offered is a hight level of compliance treated as a priority, based on fully informed 
consent?
Any of specified topics 
Does your country run trials, in addition to those on screening-specific parameters and mortality, on subsequent 
treatment procedures, clinical outcome, side effects, morbidity and quality of life?

33a Treatment procedures: Subsequent treatment procedures
33b Clinical outcomes
33c Side-effects
33d Morbidity
33e Quality of life: Morbidity
34

Assessed by pooling representative trials: Is the level of evidence concerning the effects of new methods assessed by 
pooling of trial results from representative settings?

35 Consider based on RTC, cost-effect., etc.: Does your country consider to introduce or has it introduced potentially 
promising new screening tests, which are currently being evaluated in randomised controlled trials into routine 
healthcare, once the evidence is conclusive and after having taken into account other relevant aspects, such as cost-
effectiveness in the different healthcare systems

36

In routine health care, possibly using valida-ted sur. Endpoints: Does your country consider to introduce potentially 
promising new modifications of established screening tests, once the effectiveness of the modification has been 
successfully evaluated, into routine healthcare, possibly using other epidemiologically validated surrogate endpoints?

123124 
AANNNNEEXX  66  

EEXXAAMMPPLLEESS  OOFF  EEFFFFEECCTTIIVVEE  IIMMPPLLEEMMEENNTTAATTIIOONN  OOFF  
SSCCRREEEENNIINNGG  PPRROOGGRRAAMMMMEESS  IINN  TTHHEE  EEUU  

  63

125 
  
  
  
  
 
 
Annex 6: 

Examples of effective implementation of screening 
programmes in the EU 

There  are  several  examples  of  effective  implementation  of  population-based  cancer  screening  pro-
grammes  in  the  European  Union.  Due  to  the  available  space  they  cannot  all  be  mentioned  here.  A 
number  of  examples  are  provided  below  and  in  [18].  They  include  substantial  decreases  in  cervical 
cancer mortality subsequent to introduction of population-based screening in Finland and the United 
Kingdom, and less substantial, but pronounced reductions in breast cancer mortality after introduction 
of  population-based  screening  in  Sweden,  Denmark,  or  the  Netherlands.  Scientific  investigation  and 
piloting  prior  to  nationwide  rollout  can  provide  information  essential  to  effective  programme 
implementation [32, 41, 44]. 

1 

Breast cancer screening 

The IARC and numerous other institutions and organizations have concluded that trials have provided 
sufficient evidence for the efficacy of mammographic screening of women between 50 and 69 years 
old. Women who were invited to be screened showed a reduction in breast cancer mortality averaging 
25%, with the degree of benefit depending on the particular trial. Since not all women accepted the 
invitation, the reduction among those who chose to participate in screening programmes is somewhat 
higher, being estimated, based on the trials, at 35% [19].  

1.1  Sweden 

Due  to  the  increasing  survival  of  breast  cancer  patients,  rather  long  periods  of  time  are  required  to 
assess  the  full  impact  of  service  screening  programmes  for  breast  cancer.  Sweden  is  particularly 
suited for evaluation of population-based screening because national recommendations for implemen-
tation  of  breast  screening  programmes  were  issued  in  the  mid  1980s  and  programmes  in  some 
regions  of  the  country  have  been  running  since  that  time.  Mammography  screening  is  currently 
recommended for women age 40-74 years. 

Recently, population-based mammography screening programmes have been evaluated in Sweden by 
combining  individual  breast  cancer  patient  data  with  screening  invitation  data  to  fully  document  the 
impact  upon  the  individual  woman  of  actually  receiving  the  screening  mammography  examination 
[42]. This effect was not studied by the randomised controlled trials. In a study covering women aged 
40-69 in nearly half of the country, it was found that a mortality reduction to the population of 27% 
(screened  and  non-screened  women  combined)  corresponded  to a  mortality  reduction  of  40-45%  in 
the  women  actually  screened.  Overall,  fewer  than  472  women  (95%  CI:  418-554)  needed  to  be 
screened  by  mammography  to  save  one  life  from  breast  cancer.  The  number  needed  to  screen  to 
save one life ranged from 188 to 862 in the various regions covered by the study. As to be expected, 
the longer the duration of follow-up, the lower was the number of women who needed to be screened 
to save one life. The impact of population-based service screening was significant after adjustment for 
self-selection bias. Furthermore, trends in incidence and mortality suggest that most of the mortality 
reduction  in  women  attending  screening  was  due  to  the  effect  of  screening  [43].  Given  the  long 
follow-up  period  required  to  fully  assess  the  impact  of  service  screening  for  breast  cancer,  the 
evidence gathered to date is likely to underestimate the full impact.  

1.1  Denmark 

In Denmark, the effect on breast cancer mortality has also been investigated during the first 10 years 
after introduction of mammography service screening in Copenhagen. Breast cancer mortality in the 
women  invited  to  screening  was  reduced  significantly  by  25%.  This  corresponded  to  a  mortality 
reduction of 37% in women actually attending screening [27]. 

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1.3  Finland 

In a recent study, the effect of service screening has been compared in three cities (Helsinki, Tampere 
and  Turku)  which  all  employed  different  screening  policies.  In  the  city  without  invitation  of  eligible 
women  to  screening  (Helsinki),  a  small,  non-significant  increase  in  breast  cancer  mortality  was 
observed  (11%).  In  the  city  in  which  only  part  of  the  eligible  women  were  invited  (Tampere)  the 
reduction in breast cancer mortality was non-significant (14%). In the city (Turku) in which all eligible 
women were invited to screening in the 10-year study period (1987-97) a significant 36% reduction in 
breast cancer mortality was observed[31]. 

1.4  Italy 

The  impact  of  population-based  breast  cancer  screening  programmes  has  also  been  investigated  in 
Italy. A cohort evaluation of the breast screening programme in Florence showed a 25% reduction in 
mortality with invitation to screening [28, 29]. Furthermore, earlier detection of breast cancer led to a 
significant  reduction  in  mastectomies  [30,  46].  A  large  multi-centre  case-control  study  has  been 
perfomed within the project "Impatto", the results of which are expected in the near future.  

1.5  The Netherlands 

In  the  Netherlands  the  impact  of  breast  cancer  screening  has  been  evaluated  at  the  national  level 
from  the  start  of  the  national  population-based  programme.  In  2006,  breast  cancer  mortality  in  the 
age  group  55-74  years  was  26%  lower  than  in  1986-1988  before  the  start  of  the  national  breast 
screening  programme  in  1989  [25].  A  substantially  higher  impact  in  the  group  of  women  actually 
attending screening may also be expected. 

2 

Cervical Cancer Screening 

Cytological screening at the population level every three to five years can reduce cervical cancer in-
cidence  up  to  80%  [20].  This  decrease  results  from  early  detection  of  cervical  cancer  precursor 
lesions,  that  is,  lesions  which,  if  appropriately  treated,  will  not  progress  to  invasive  cancer.  If  impl-
emented effectively, screening can reduce cervical cancer mortality to a similar degree.  

2.1  Finland 

In  Finland  (population  5  million)  organised  cervical  screening  was  introduced  in  the  early  1960s; 
piloting first within the area of three municipalities in 1963 and extending within a few years to most 
parts of the country. By 1970, the coverage of the population-based programme was already above 
80% of women in the target age group. Furthermore, from the early 1970s onwards, the registered 
coverage  has  become  almost  complete  in  these  target  age  groups.  By  the  early  1990s  the  age-
standardised  incidence  of  cervical  cancer  had  decreased  by  70-80%.  Subsequently,  the  reduction  in 
cervical  cancer  mortality  was  even  more  pronounced.  Coverage  of  the  target  population  is 
approximately 90% and participation is over 70% [2]. These developments have enabled Finland to 
reach  the  lowest  level  of  cervical  cancer  incidence  and  mortality  currently  reported  in  the  EU  (4.9 
cases/100,000 women and 1.6 deaths/100.000 women).35 Particularly noteworthy is the comparatively 
low  number  of  screening  examinations  in  a  woman's  lifetime  which  is  required  to  achieve  such 
benefits.  Due  to  the  five-year  screening  interval  and  the  30-60-year  age  range  of  the  target  popu-
lation, women with normal results are only invited to a total of 7 examinations. Avoiding unnecessary 
screening examinations improves the balance between harm and benefit of screening and has a sub-
stantial impact on cost-effectiveness. 

35 Incidence and mortality rates are age adjusted (European standard population). 

  69

127 
 
 
 
 
 
 
                                                 
2.2  The Netherlands 

The  Netherlands  is  another  Member  State  in  which  rates  of  cervical  cancer  have  reached  very  low 
levels  after  nationwide  implementation  of  a  population-based  cervical  screening  programme.  At  the 
same  time,  unnecessary  use  of  resources  for  screening  has  been  avoided.  This  is  reflected  in  the 
same low minimum number of screening examinations to which women are invited in a lifetime as in 
Finland  (7  invitations  to  30-60-year-old  women,  once  every  five  years).  The  programme  was 
reorganised in the mid 1990s [36] and cervical cancer rates have in the meantime reached the third 
lowest  level  of  incidence  (8.0  cases/100,000)  and  the  fifth  lowest  level  of  mortality  (3.0  deaths/ 
100,000)  in  the  EU  27.  Currently  cervical  cancer  mortality  in  the  Netherlands  is  more  than  five-fold 
lower than in the Member State with the highest rate (Table 1). 

2.3  Italy 

Before the 1990s most cervical cancer screening in Italy was performed outside of population-based 
programmes [40]). A population-based programme started in Turin in 1992 in a population in which 
some  spontaneous  screening  was  already  present.  Between  1992  and  1998,  a  20%  incidence 
reduction  was  observed  among  invited  vs  uninvited  women  and  a  more  than  70%  reduction  of 
cervical cancer incidence was associated with attendance to the programme [39]). 

Nationwide implementation of population-based cervical cancer screening programmes on a regional 
basis  has  been  recommended  in  Italy  since  1996. Recommendations are  largely  based  on  European 
Guidelines and include personal invitation of women aged 25-64 years to Pap tests every three years, 
a  monitoring  system,  and  quality  assurance  procedures  for  each  programme  phase  (for  references 
see: [38]). Within less than ten years, active programmes in Italy had a target population accounting 
for  nearly  two-thirds  of  the  nationwide  population  25-64  years  of  age.  This  process  and  continuous 
improvement  in  effectiveness  is  expediated  by  the  National  Centre  for  Screening  Monitoring,  which 
issues annual reports on programme implementation, activity levels and process indicators, to which 
all  loco-regional  programmes  contribute.  The  positive  impact  of  screening  is  also  reflected  in  the 
current 7th and 2nd lowest national rates of cervical cancer incidence (9.5 cases/100,000) and mortality 
(2.6 deaths/100,000), respectively, compared to other EU Member States (Table 1).  

2.4  United Kingdom 

The  introduction  of the UK  cervical screening  programme  is another  example of  the  profound  effect 
that  a  population-based  screening  programme  can  have  on  the  burden  of  the  disease  in  the  pop-
ulation.  In  the  two  decades  prior  to  introduction  of  the  programme  (1967-1987)  cervical  cancer 
mortality rose three-fold in England and Wales in women younger than 35 years. By 1988, when the 
call-recall system was started, incidence in this age-range was among the highest in the world despite 
substantial  opportunistic  screening.  These  dramatic  trends  were  reversed  by  introduction  of  the 
population-based programme. During the decade after the start of the programme, screening cover-
age in England doubled and invasive cervical cancer mortality rates decreased by approximately 50%. 
It has been estimated that in the absence of the national population-based programme approximately 
5,000 additional deaths per year due to cervical cancer would now be occurring [34]. 

3 

Colorectal cancer screening 

Population-based  colorectal  cancer  screening  is  a  comparatively  new  tool  of  cancer  control.  Current 
evidence of the efficacy and effectiveness of screening is based on trials (for references see [35, 18]) 
because  service  screening  programmes  are  lacking  or  are  in  the  early  implementation  phase.  The 
paucity of experience with effective screening programmes for colorectal cancer underlines the need 
for  conducting  pilot  programmes  and studies  prior to  rollout  across a  country or  region.  In  the  pilot 
phase,  protocols  and  procedures  can  be  developed,  tested  and,  if  necessary,  improved  before 

68

128 
 
 
 
 
widespread  implementation.  The  experience  and  results  of  piloting  enable  responsible  authorities  to 
make  better  informed  decisions  about  programme  implementation  and  planning,  and  provide  data 
relevant to cost-effectiveness analysis. The lessons learned may also save substantial time and effort 
in the programme rollout phase by raising the knowledge base in all regions of the country. 

3.1  Piloting colorectal cancer screening in the United Kingdom 

Beginning in March 2000, nearly half a million residents in two pilot areas in England and three pilot 
areas in Scotland were invited to take part in a demonstration pilot screening programme to test the 
feasibility  of  a  national  screening  programme  for  colorectal  cancer  based  on  the  faecal  occult  blood 
test (FOBT). The results of the first round of the pilot were published in July 2004. They showed that 
the  short-term  outcomes  believed  necessary  to  bring  about  a  reduction  in  mortality  from  colorectal 
cancer can be achieved by the UK's NHS outside the context of a randomised trial. 

However,  the  pilot  experience  and  results  pointed  to  a  number  of  aspects  which  required  special 
consideration in the planning and implementation of the national programme: for example, the higher 
than  expected  acceptance  of  screening  by  elderly  men  and women;  the sensitivity  and specificity  of 
the  faecal  occult  blood  test  and  the  distribution  of  screen-detected  lesions  under  routine  screening 
conditions  in  the  target  population;  the  higher  positivity  rate  of  the  FOBT  and  the  higher  rate  of 
detected  cancers  in  Scotland  than  in  England;  and  the  need  for  accelerated  training  programmes  in 
colonoscopy  for  assessment  of  screen  positives.  Knowing  these  issues  in  advance  facilitated  the 
planning  and  implementation  of  the  national  programme  and  also  underlined  that  introduction  of 
screening must go hand-in-hand with improvements in provision of services [44]. 

Rollout  of  colorectal  cancer  screening  began  in  England  in  2006  (2-yearly  FOBT,  age  60-69)  and  in 
Scotland in 2007 (2-yearly FOBT, age 50-74). Rollout will begin in Wales in 2008 (2-yearly FOBT, age 
50-74) and, pending a final decision by the responsible authorities, will also begin in 2008 in Northern 
Ireland. In England, residents 70+ years may request FOBT screening when the programme reaches 
their region; phasing in of invitation to age 75 will begin in 2010. 

3.2  Rollout of population-based colorectal cancer screening in Finland 

Rollout  of  the  national  colorectal  cancer  screening  programme  in  Finland  began  in  2004.  The 
programme  is  expanding  gradually  and  by  randomization.  It  is  too  early  to  measure  the  effect  of 
screening in the target population, but the programme design permits evaluation. In 2007 about one-
third  of  the  Finnish  population  was  covered.  During  2004-2006,  nearly  71%  of  persons  invited  to 
attend  screening  complied.  Overall,  women  took  part  more  readily  than  men,  with  the  best 
participation rate, of 78%, among women, while that of men was 63%. Among the screened, 2.1% 
were  found  with  blood  in  stools,  3%  of  men  and  1.5%  of  women.  Cancers  and  adenomas  were 
detected  according  to  expectations,  in  8.6%  and  43.2%,  respectively,  among  those  who  underwent 
colonoscopy [24].  

  71

129 
 
 
130 
AANNNNEEXX  77  

WWEEBBSSIITTEESS  OOFF  SSCCRREEEENNIINNGG  PPRROOGGRRAAMMMMEESS  IINN  EEUURROOPPEE  
CCOOLLLLEECCTTEEDD  IINN  TTHHEE  EEUUNNIICCEE  PPRROOJJEECCTT  

131  
  
  
  
132 
Annex 7:  Websites of Screening Programmes in Europe collected in the 

EUNICE projec 

WEB SITES 

www.nic-ima.be/nl/projects/mammo/context_goal/ 

COUNTRY 

BELGIUM 

CZECH REPUBLIC 

www.mamo.cz  

FRANCE 

Ademas 
Isere 
France general 

www.ademas-alsace.com 
www.odlc.org/ 
www.rendezvoussanteplus.net/ 

GERMANY 

www.kooperationsgemeinschaft-mammographie.de/home/home.php 

ICELAND 

www.krabb.is  

IRELAND 

www.nbsp.ie  

ITALY 

www.gisma.it 

www.osservatorionazionalescreening.it  

LUXEMBOURG 

www.mammographie.public.lu/ 

NORWAY 

www.kreftregisteret.no  

PORTUGAL 

www.ligacontracancro.pt/ 

SPAIN 

www.programascancerdemama.org/ 

www.sp.san.gva.es/DgspWeb/ppcm/ 

THE NETHERLANDS  

www.bevolkingsonderzoekborstkanker.nl/ 

UNITED KINGDOM 

www.cancerscreening.nhs.uk  

SWITZERLAND 

Fribourg CH 
Genève CH 

www.liguecancer-fr.ch/fr/ 
www.fgdcs.ch/accueil/index.php 

133 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
134 
AANNNNEEXX  88  

LLIISSTT  OOFF  AABBBBRREEVVIIAATTIIOONNSS  

135 
  
  
  
  
  
Annex 8: 

List of Abbreviations 

CRC Cancer 

Colorectal Cancer 

CS 

Colonoscopy 

DG SANCO  Directorate-General for Health and Consumers of the European Commission 

E-ASR 

European age-standardized rates 

ECN 

European Cancer Network 

ENCR 

European Network of Cancer Registries 

EU 

European Union 

EUNICE 

European Network for Information on Cancer 

EUROSTAT 

Statistical office of the European Communities 

FOBT 

Faecal Occult Blood Test 

FS 

Flexible Sigmoidoscopy 

IARC 

International Agency for Research on Cancer 

IBSN 

International Breast Screening Network 

LT 

Lifetime 

natw 

Nationwide 

non-pop-b  Non-population-based 

no prog 

No programme 

pilot 

plan 

Piloting 

Planning 

pop-b 

Population-based 

QT 

reg 

RCT 

Audit system on Quality of breast cancer diagnosis and Treatment 

Regional 

Randomized Controlled Trial 

rollout cmp  Rollout complete 

rollout ong  Rollout ongoing 

SEED 

European Screening Evaluation Database 

yr 

Year 

136 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
European Commission 

Cancer screening in the European Union. Report on the Implementation of the Council 
Recommendation on cancer screening – First Report 

von Karsa L, Anttila A, Ronco G, Ponti A, Malila N, Arbyn M, Segnan N, Castillo-Beltran M, Boniol M, Ferlay J, Hery 
C, Sauvaget C, Voti L, Autier P (authors) 

Printed by the services of the European Commission 

2008 – 136 pp. – 29,7 x 21 cm 

ISBN 978-92-79-08934-3 

  71

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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