Early Detection Saves Lives
Isabel Rubio and Jan Van Meerbeeck, Co-Chairs of the European Cancer Organisation’s Prevention Network, opened the session, subtitled Taking European Cooperation on Cancer Screening to the Next Level.
Rubio highlighted that while screening and other prevention policies can help improve cancer outcomes and reduce mortality, they can be controversial. There is also huge room for improvement and novel screening programmes are required.
The Network is therefore working with participating organisations to implement prevention more widely as the most effective long-term strategy for cancer control. To those ends it also developed a resolution, voted on at the end of the session.
Row 1 - Jan Van Meerbeeck (European Cancer Organisation’s Prevention Network) Harry De Koning (Erasmus MC University) Padraic Ward (Roche). Row 2 - Isabel Rubio (European Cancer Organisation’s Prevention Network); Stefan Gijssels (European Cancer Organisation’s Patient Advisory Committee); Frances Fitzgerald M ht (Innovative Partnership for Action Against Cancer); Partha Basu (World Health Organization).
Creating Benefits at All Levels
Stefan Gijssels, Co-Chair of the European Cancer Organisation’s Patient Advisory Committee, said good screening leads to better cancer treatment, and better survival and quality of life for patients. It also incurs less costs, less disruption, fewer complications and less financial hardship.
In all cases, it is better to diagnosed with cancer at an early than late stage. For example, stage I colorectal cancer (CRC) is associated with 90% survival versus 10% for stage IV disease, and treatment costs are ten times lower. However, only 13% of CRC cases in Europe are diagnosed in stage I, despite it being easy to detect and very common.
The exception is the Netherlands, where the proportion of CRC patients diagnosed in stage I is 48%. Achieving that is not a pipe dream but is possible with available technology. If it were repeated Europe-wide, 130,000 lives would be saved each year. The direct healthcare savings would reach €3 billion, while a UK analysis including indirect costs put the total at €9 billion.
However, achieving this requires better investment in early-stage detection and management, and doctors need to ask patients more often about their family history.
Quality Assurance is Key to Successful Screening
Tit Albreht, Coordinator of the Joint Action, Innovative Partnership for Action Against Cancer (IPAAC), said that there have been three joint actions on cancer prevention: EPAAC,[20] covering quality assurance of screening programmes; CanCon,[21] which assessed the three recommended screening programmes and proposed four others; and now IPAAC,[22] which is focused on the European Code Against Cancer and reviewing existing and potential screening programmes.
As science develops, guidelines around screening and early detection will need updating more frequently, and there remain many quality assurance challenges. Crucially, early detection is a necessary complement to screening, as not all cancers can be screened but they may all be detected early.
For existing programmes, information needs to be shared and implementation challenges understood. Crucially, one size does not fit all, and programmes should undergo HTAs. Better implementation requires a stepwise approach, with continuous measurement of success, and linkage to population registries. Behavioural issues around participation also should be emphasised.
New screening programmes should follow a jointly developed recommendation on the screening criteria, supported by protocols. Again, there should be an emphasis on behavioural issues related to participation, and careful consideration of the risks and potential harms to healthy individuals, as well as an economic evaluation and assessment.
Minimising Harms, Maximising Benefits
Partha Basu, Head of the Screening Group at IARC, said that all screening programmes do harm, but some do more good than harm, at a reasonable cost. The best way to minimise harms and maximise benefits is to implement screening via a population-based approach with quality assurance, all within a defined framework. In addition, data should be collected in a systematic manner and compared with current standards.
He pointed to the 2017 Report on the implementation of the Council Recommendation on cancer screening,[23] which showed 72% of people aged 50–69 years in 20 EU Member States had access to CRC screening, far higher than in the first report in 2007. However, there remain large gaps in the datasets around screening that can impede analysis of their performance.
Across breast, cervical and colorectal cancer screening, only 25% of countries could provide an adequate dataset, with up to 20% providing information on further assessment and cancer detection rates. Moreover, the data gap was far wider for cervical than breast cancer. Basu said a third report on screening implementation is clearly needed. The 2017 report encouraged countries to collect, harmonise and report data, but the third should dive deeper to understand the underlying issues, and ensure more men and women are saved.
Screening Version 3.0
Harry De Koning, Professor of Public Health and Screening Evaluation at the Erasmus MC University, believes that screening in Europe needs to go to ‘Version 3.0’, using well-validated tools to quantify harms and benefits and assess costs. For that, high-quality data on long-term outcomes are needed, with programmes interacting locally, regionally, nationally and on the EU level to reduce inequalities.
He said every country should follow the example of Slovenia and publish an optimal protocol for cervical cancer screening, based on cost-effectiveness. The example of breast screening should also be used so programmes learn from each other.
While breast and cervical screening programmes are extremely cost-effective, De Koning said prostate and lung screening are a little less cost-effective but can still have more benefits than harms, and potentially more so than cervical screening. However, prostate and lung screening will need properly quality assurance and upper age limits, as well as risk-based selection in the case of lung cancer.
There is also a need for large scale prevention cohorts, stratifying individuals by their initial test result. As smoking is linked to both cancer and cardiovascular disease, they could be combined into one prevention programme, representing a paradigm shift in disease prevention.
Personalised Healthcare for All
Padraic Ward, Head of Commercial Operations at Roche, said cancer care is better than ever before but needs to be much better. Better therapies, better access and better screening could add up to personalised healthcare, in which everyone has the right intervention at the right time, even if that means no medical therapy.
There are currently a number of advances in molecular technologies, including liquid biopsies, that are helping to understand tumour biology and, if used in a coordinated fashion, could improve outcomes. However, meaningful data at scale is necessary to achieve this, which requires a common EU data space.
A Pivotal Time
Frances Fitzgerald MEP said the European Cancer Summit 2020 is happening at a pivotal time, as cancer is struggling against priorities not only around health and COVID-19 but also a number of other pressing issues. During the pandemic, cancer screening was seen as non-essential and it is important this does not happen again. Key to that is translating what experts say into understandable language and clear messages to reduce confusion. Nevertheless, COVID-19 has given a new awareness at a political level of health issues and their impact on economies. That needs to be built on at a European level, especially via the numerous groups and committees with a focus on cancer, as cancer screening and prevention is an example of how inequalities across EU Member States can be tackled.
In the following discussion, Albreht said that artificial intelligence can help with modelling and optimising screening programmes, while Gijssels underlined that we need to reach out to vulnerable communities, and address patients’ fears over cancer and screening.
