" EUROPE AGAINST CANCER " PROGRAMME: PROPOSAL FOR A PLAN OF ACTION 1987-1989

26. 2. 87 Official Journal of the European Communities No C 50/1
II
(Preparatory Acts)
COMMISSION
'EUROPE AGAINST CANCER' PROGRAMME
Proposal for a plan of action, 1987 to 1989
including a proposal for a Council Decision on informing the general public and the training of
members of the health professions
COM(86) 717 final
(Submitted by the Commission to the Council on 17 December 1986)
(87/C 50/01)
PRELIMINARY REMARKS
In June 1985, in Milan, and in December 1985, in Luxembourg, the Heads of State and of
Government of the 12 Member States of the European Community stressed the importance of
launching a European programme in the fight against cancer, so that the construction of Europe could
make the necessary contribution to combatting this scourge, but also take on a new dimension, closer
to the concerns of citizens.
In order to implement that conclusion of the European Council and prepare a proposal for a 'Europe
against cancer' programme, a committee of leading cancer experts (!) was set up in January 1986
under the auspices of the Commission of the European Communities. The following proposals cover
the first three years of implementation of the programme. They are based to a large extent on the
conclusions of thai: committee, whose readiness and commitment, and the high calibre of its work
should be stressed.
In addition, this work has benefited significantly by the studies and research carried out or underway
in the World Health Organization, and in its International Agency for Research on Cancer.
Four areas are covered by this proposal for a plan of action for the period 1987 to 1989:
— cancer prevention: On 7 July 1986, a resolution was adopted by the Council and the
representatives of the Governments of the Member States meeting within the Council which lays
down the main lines for the preventive part of the European programme of action against
cancer (a). The present communication completes this programme by identifying about 30
Community, actions,
— information and health education of the general population and training of health care workers in
cancer, for which a proposed Council Decision is attached to the present communication,
t1) The committee consists of the following figures: Prof. C. de Duve, substitute, Prof. Boon (Belgium), Prof. C.
Schmidt (Federal Republic of Germany), Prof. E. Grundmann (Federal Republic of Germany), Dr O. Moeller
Jensen (Denmark), Prof. J. Estape (Spain), Prof. M. Tubiana (France), Dr S. Vassilaros (Greece), Dr M.
Moriarty (Ireland),Prof. U. Veronesi (Italy), Prof. M. Dicato (Luxembourg), Dr R. Kroes (Netherlands), Prof.
J. Conde (Portugal) and Prof. N. Bleehen (United Kingdom). From January 1987 Sweden will be represented
by Prof. J. Einhorn, as an observer.
(2) OJ No C 184, 23. 7. 1986, p. 19.
No C 50/2 Official Journal of the European Communities 26. 2. 87
— cancer research: In November 1986 the Commission forwarded to the Council of Ministers of the
European Communities a proposed Regulation (!) on a fourth programme for coordination in
medical research (1987 to 1989). The present communication clarifies and details the cancer
research dimension.
Some of the actions which are foreseen come directly under the Commission's management powers.
They will be carried out as such in that manner, beginning in 1987 for the majority of them. This
communication also contains many proposed actions which the Commission intends to send, in 1987
to 1989 to the European Parliament, for consultation, and the Council of Ministers of the European
Communities, for approval. They are therefore liable to be amended at a later stage.
(') Doc. COM(86) 549 final, 29. 10. 1986.
26. 2. 87 Official Journal of the European Communities No C 50/3
TABLE OF CONTENTS AND SUMMARY
General introduction 6
CHAPTER 1: CANCER PREVENTION 8
I. CAMPAIGN AGAINST TOBACCO
Proposed action 1 (*):• Upwards alignment of taxation on tobacco manufactured in the European
Community 11
Proposed action 2: Financing of preventive actions at national level by the use of increased fiscal measures on
tobacco 12
Action 3 (2): Publication of indices excluding tobacco by the Statistical Office of the European
Communities 12
Proposed action 4: Harmonization of cigarette labelling in the European Community 12
Proposed action 5: Prohibition of cigarettes with a high tar content 12
Proposed action 6: Harmonization of the standards for the components of tobacco smoke 12
Proposed action 7: Prohibition of tax-free sales of tobacco in the European Community 13
Proposed action 8: Protection of children from tobacco sales 13
Proposed action 9: Reorientation of tobacco production towards less toxic varieties and study of the
possibilities of reconversion 13
Proposed action 10: Information and public awareness campaign in the struggle against tobacco 14
Proposed action 11: Study of national provisions, and development of proposed Community regulations on
tobacco smoking in public places 14
Proposed action 12: Study of national provisions, and development of proposed Community regulations on
the limitation of tobacco publicity 14
Action 13: Comparative analysis of anti-smoking campaigns 14
Action 14: Information exchange in the struggle against smoking 14
II. IMPROVEMENT IN NUTRITION
Action 15: Analysis of existing information on 'nutrition and cancer' 18
Action 16: Development of nutritional recommendations against cancer adapted to each of the categories of
participants concerned 18
Proposed action 17: Harmonization of nutritional labelling of foodstuffs in the European Communities 18
Proposed action 18: Consumer protection against certain agents in foodstuffs 18
Action 19: Improvement of existing information campaigns concerning nutrition 18
Action 20: Initiation of information campaigns for recommended foodstuffs 19
Proposed action 21: Promotion of appropriate foodstuffs and techniques 19
Action 22: Evaluation of pilot experiments in nutrition 19
Action 23: Exchange of information on 'nutrition and cancer' 19
HI. PROTECTION AGAINST CARCINOGENIC AGENTS
Proposed action 24: Protection against ionizing radiations and follow-up to Chernobyl 27
Action 25: Creation of an observation antenna and establishment of a list of chemical substances suspected of
being carcinogenic 27
Action 26: Speeding-up of the work at Community level, and creation of a special group on classification and
labelling of carcinogenic substances 27
Proposed action 27: Adoption of Directives currently being discussed by Council for the protection of
workers 29
Proposed action 28: New Directives for the protection of workers against carcinogenic substances . . . . 29
Proposed action 29: Prevention of occupational cancers by improving the practical organization in
undertakings, including information to employers and workers 29
Proposed action 30: New measures for public protection against carcinogenic substances 30
i1) These proposed actions will be prepared by the Commission of the European Communities and submitted
from 1987 to 1989 to the European Parliament, for consultation, and to the Council of Ministers of the
European Communities, for adoption.
(2) The actions as stated will be put into effect by the Commission of the European Communities using its
management powers, mostly from 1987.
No C 50/4 Official Journal of the European Communities 26. 2. 87
IV. SYSTEMATIC SCREENING AND EARLY DIAGNOSIS
Action 31: Promotion of a policy for systematic screening and early diagnosis of cancer of the uterine cervix
and cancer of the breast 31
Action 32: Evaluation and improvement of the policy for the systematic screening and early diagnosis of
other common cancers 32
V. EUROPEAN CODE AGAINST CANCER
Action 33: Transformation into layman's language of the European code against cancer 33
CHAPTER 2: INFORMATION AND HEALTH EDUCATION IN THE PREVENTION OF
CANCER 33
I. INFORMING THE GENERAL PUBLIC
Action 34: Establishment of a directory of the private organizations against cancer in Europe 34
Action 35: Comparative survey of private and public cancer prevention information campaigns 35
1. Actions planned in 1987
Action 36: Bringing cancer prevention and the 'Europe against cancer' programme to the attention of the
media 35
Action 37: Eurobarometer survey of Europeans' attitudes to cancer and its prevention 35
Action 38: Financial contribution to television cancer prevention broadcasts for the general public 36
Action 3 9: Dissemination of the European code against cancer at sports and cultural events sponsored by
the European Community 36
Action 40: Public meeting to mark the end of the first year of the 'Europe against cancer'
programme 36
Action 41: Preparation of the actions to be carried out in 1989, 'European information on cancer
year' 37
2. Proposals for action in 1988
Proposed action 42: Organization of a European week against cancer which will serve as a test for the
1989 campaign for the European information on cancer year 37
Proposed action 43: Increase in 1988 of the campaigns carried out in 1987 to inform the public and
increase public awareness of the campaign against cancer 37
3. Proposals regarding the European information on cancer year (1989)
Proposed action 44: Interesting teachers and the health professions in dissemination of the European
cancer prevention commandments 38
Proposed action 45: Organization of a media campaign aimed at the general public: 12 nations, 12 days
of action against cancer 38
Proposed action 46: Intensification in 1989 of the campaigns carried out in 1987 and 1988 to inform the
public and increase public awareness of the fight against cancer 38
II. HEALTH EDUCATION
Action 47: Establishment of a comparative survey of health education programmes in European schools 39
Proposed action 48: Drawing-up of proposals to improve health education programmes in schools . . . . 39
Proposed action 49: Provision of teaching material relating to health education 39
Proposed action 50: Contribution to the financing of television health education broadcasts on the
prevention and treatment of cancer 39
CHAPTER 3: TRAINING OF THE HEALTH PROFESSIONS 39
Action 51: Comparative study of the systems of university training for health care workers 42
Proposed action 52: Formulation of proposals for improving the organization of studies in the cancer
field 43
Action 53: Stimulation of mobility of medical and nursing students 43
Proposed action 54: Joint preparation and exchange of teaching materials and testing of this during the
European information on cancer year 44
Action 55: Exchange of experience on continuous training 44
Proposed action 56: Development of common computer programmes for expert medical systems for
cancer 44
26.. 2 . 87 Official Journal of the European Communit ies N o C 5 0 / 5
CHAPTER 4: CANCER RESEARCH 44
Proposed action 57: European grants to encourage the mobility of cancer research workers 46
I. RESEARCH TO IMPROVE THE PREVENTION,
SCREENING AND DETECTION OF CANCER
A. Improvement of information systems regarding the frequency and nature of cancers 46
Action 58: Comparison of existing cancer registers and recommendations for their minimum contents
and conditions of access to them 46
B. Epidemiological research to improve prevention 47
Proposed action 59: Launching European coordination of medical research on food and cancer . . . 47
Proposed action 60: Stepping-up of European research on occupational cancers 47
Action 61: Continuation of the cofinancing by the European Community of research on the prevention
of radiation-induced cancers 48
Action 62: Continuation of cofinancing by the European Community of research on carcinogenic factors
in the environment 48
Proposed action 63: Launching of European coordination of medical research on cancer and
reproduction 48
Proposed action 64: Launching of European coordination of medical research on passive smoking 48
C. Research to improve screening and diagnosis 49
Proposed action 65: Continuation of European coordination of medical research on automated tissue
analysis 49
Proposed action 66: Continued European coordination of research on imaging in medicine 49
II. RESEARCH ON CANCER THERAPY
Proposed action 67: Strengthening of European coordination of medical research on control of multicentre
therapeutic trials 50
Action 68: Cofinancing of a European network of data banks for cell cultures producing monoclonal
antibodies 51
Action 69: Cofinancing by the European Community of research into genetic engineering and protein
engineering for the manufacture of anti-cancer drugs 52
Proposed action 70: Cofinancing by the European Community of research on the targeting of cancer-killing
drugs 52
Proposed action 71: Cofinancing by the European Community of research on the pharmacology of
anti-tumour substances 52
Proposed action 72: Harmonization of testing standards for anti-cancer drugs 53
III. FUNDAMENTAL CANCER RESEARCH
Proposed action 73: Cofinancing by the European Community of research into the genome and human
oncogenes 54
Proposed action 74: Cofinancing by the European Community of research on nucleic acid probes . . . . 54
CONCLUSION
Action 75: Regular evaluation of the action plan, 1987 to 1989, with the European Committee of Cancer
Experts and establishment of an overall assessment in 1989 55
Proposal for a Council Decision adopting an action plan, 1987 to 1989 , on informing the general
public and training of the health professions in the context of the programme 'Europe against
cancer' 56
No C 50/6 Official Journal of the European Communities 26. 2. 87
GENERAL INTRODUCTION
Going back probably to the origins of man (the Kanam jawbone, which is some 500 000 years old,
already shows signs of the disease (1)), varied in its manifestations (several hundred different types are
observed today), extremely widespread in our developed societies (one European in four today has
been, is being or will be affected), cancer is still considered as a mysterious disease characterized by the
disorganization of certain cells and their anarchical proliferation, for reasons about which more and
more is being learned but that have not so far been totally elucidated. Moreover, if the increase
observed in recent years were to continue, by the year 2000 one European in three would be stricken
by cancer at some time in his life.
Although worrying, the picture is not, however, altogether sombre. Clearly, the rise in the number of
cancer cases can be accounted for by the increase in the average lifespan, since the incidence of cancer
increases rapidly with age. Moreover, cancer is only the second largest cause of death in man, after
cardiovascular diseases.
All the same, like the infectious diseases in previous centuries, cancers are the most feared form of
illness today, probably because treatment is still too often at the cost of surgical mutilation or
undesirable side effects, and probably also because, until the recent invention of effective
pain-suppressant drugs, cancer frequently caused prolonged and unbearable suffering.
Nevertheless, we no longer have to accept that cancer is a fatal disease. It is a fact that the frequency of
cancer should be reduced by prevention, and treatment improved through therapeutic research. The
current state of our resources renders long-term survival, if not complete cure, possible in nearly half
the cases, whereas scarcely one-quarter of patients were cured in 1950 (2). Above all, cancer is often
avoidable, as can be seen from the considerable successes registered in certain countries in combating
three common types of cancer.
The spectacular reduction in the number of stomach cancers in the developed countries can thus
probably be ascribed to more wholesome food, free from microbial proliferation (thanks to
refrigerators and probably also thanks to antioxidant food additives). The fall in the frequency of
cervical cancer, a disease that is increasingly thought to be sexually transmitted can, for its part,
probably be attributed to more regular gynaecological screening and improved standards of hygiene in
both sexes. Lastly, in countries such as the United States and the United Kingdom, a drop in the
frequency of lung cancer is being observed today, such countries having begun anti-smoking
campaigns earlier than others.
Through better prevention and through more effective treatment, improved by research, Europeans
can in future hope to achieve a further big reduction in the death rate due to cancer and the number of
persons afflicted. The struggle against cancer concerns everyone at all levels. For its part, European
agriculture and industry can harmonize its regulations and techniques so that the day-to-day
environment in which Europeans live is improved and rid of cancer-inducing factors. As regards
European research and technology, it can boost the effectiveness of private and public research efforts
through a more efficient coordination of its human and financial resources.
(!) Origine et devolution de I'homme, National Museum of Natural History, Paris, 1984.
(2) M. Tubiana, he cancer, Presses Universitaires de France, Paris, 1985.
26. 2. 87 Official Journal of the European Communities No C 50/7
Trends in the number of new cases of cancer in Denmark 1943 to 1980
(age-standardized, per 100 000 inhabitants)
MEN
100.0-
10 .0 .
1.0.
Lung
Stomach
Prostate
. ~^JZ^- Bladder
; Rectum
>- "^ r"
_ Pancreas
"""" .-.Melanoma
^mi'-^r L a r y n x
"""" * -^.- Leukemia, ANLL
Oesophagus
Pharynx
0.1
1945
T
1950 1955 1960 1965 1970 1975 1980
WOMEN
100.0
10.0 _ -
1.0 .
0.1
Stomach
_-—»,__ Cervix uteri
'. ^. Corpus uteri
•-»*** Ovarv
Rectum
Melanoma
•J"S. Pancreas
Bladder
Leukemia, ANLL
" • Oesophagus
- ^ Pharynx
1945 1950 1955 1960 1965 1970 1975 1980
Source: Ole Moeller Jensen et al, Cancer registration in Denmark — National Institute Monograph No 65,
pp. 245—251.
Note: Set up in 1942, the Danish cancer register is the oldest of its kind in Europe. It can be used to monitor
long-term trends in the number of cancer cases.
N o C 50/8 Official Journal of the European Communities 26. 2. 87
CHAPTER 1
CANCER PREVENTION
(including early detection)
It is now a very long time since shrewd observers first noted the link between the incidence of certain
types of cancer and the lifestyle and working conditions of those affected. The most perspicacious of
these was undoubtedly the English doctor, Percival Pott. As early as 1775 he drew the medical
profession's attention to the probable role played by soot in cancer of the scrotum, a disease frequently
suffered by factory chimney-sweeps. His observation was to be confirmed two centuries later when, in
1915, the Japanese doctors Yamigiwa and Ichikawa induced malignant tumours in rabbit ears daubed
regularly with tar.
One of the great advances in 20th-century medicine has been to establish the effect of life-styles,
working conditions and the environment on the incidence of cancer. Epidemiological research has
played a decisive part in this area. Thus, studies carried out among American religious sects which
forbid tobacco and alcohol (the Mormons and the Seventh Day Adventists) have demonstrated that
the frequency of cancer as a whole among these people is half what it is in other Americans of the same
age, sex and occupations, not bound by the same prohibitions. Other studies performed among
migrant populations have also led to significant conclusions. For example, the frequency of stomach
cancer, which is very common in Japan, has been found to decrease over the 15 years following the
emigration of Japanese to the United States. The same Japanese, however, then become vulnerable to
cancer of the colon or rectum, as are the Americans themselves. These geographical differences in the
frequency of different types of cancer and the varying degrees of vulnerability according to lifestyle
have suggested that in the vast majority of cases, cancer in human beings is caused by external
factors.
Several studies have attempted to quantify the relative importance of these various risk factors. The
conclusions of the various authors, taken all together, are reasonably close, one to another. For
example, in their 1981 report on the causes of cancer in the United States, the British epidemiologists
Richard Doll and Richard Peto (a), world authorities on the subject, concluded that over
three-quarters of the number of deaths caused by cancer are linked with external factors (see Table 1).
In certain cases, such as smoking, their conclusions are baldly unambiguous. As far as other factors
such as eating habits are concerned, much uncertainty remains and, therefore, further research is
needed. These particular findings are, of course, based on the United States and their value is only
indicative as far as the European countries are concerned. Nevertheless, they do provide a first
approximation of the situation, except perhaps in the case of alcohol, which plays a far more
significant role in countries such as France where it is implicated in over 10 % of all deaths from
cancer.
It is outstandingly clear from the points made above that cancer can often be avoided if both society
and the individual are prepared to adapt their legislation and behaviour to derive the greatest possible
benefit from existing knowledge of cancer prevention. In the view of European cancer specialists,
between now and the year 2000 the European countries could join forces to reduce cancer mortality
by 1 5 % .
(]) R. Doll and R. Peto, The Causes of Cancer, Oxford University Press, Oxford, New York, 1981.
26. 2. 87 Official Journal of the European Communities No C 50/9
Table 1
Proportion of deaths from cancer attributable to different factors. The case of the United States
Factor or category of factors
Tobacco
Alcohol
Eating habits
Food additives
Sexual and reproductive habits
Occupation
Pollution
Industrial products
Medicine and medical processes
Geophysical factors
Infections
Percentage of all deaths
caused by cancer
Best
estimate
30
3
35
1
7
4
2
1
1
3
10?
Variation in
estimates
25 to 40
2 to 4
10 to 70
—5 to 2
1 to 13
2 to 8
1 to 5
1 to 2
0,5 to 3
2 to 4
1 to ?
Source: R. Doll and R. Peto.
I. CAMPAIGN AGAINST TOBACCO
1. Tobacco and Cancer
It was not until 1950, when the British doctors R. Doll and A. B. Hill published their findings (*), that
a link began to be clearly established between heavy smoking and lung cancer. Since then over 40
carcinogenic substances have been identified in tobacco smoke and numerous studies of patients
suffering from lung cancer have shown a link with smoking in at least 90 % of cases. The results of
these epidemiological studies have been confirmed and consolidated by regular follow-up over many
years of the health status of hundreds of thousands of people, all of whom were initially in good
health. It was thus discovered that the frequency of cancer of the bronchi was proportional to the
number of cigarettes smoked per day. It is 20 times greater, for example, in those who smoke 20
cigarettes than in those who smoke only one (2). Furthermore cancer is also more frequent in all tissues
entering into contact with tobacco smoke: the lips, mouth, tongue, larynx, pharynx, oesophagus,
pancreas and lungs. The same also applies to the kidneys and bladder because smoke residues pass into
the blood and are eliminated in urine.
On the other hand, when a smoker gives up smoking, his excess mortality due to lung cancer falls
gradually over 10 to 15 years, after which his life expectancy is again equal to that of a non-smoker (3).
Furthermore, the curves of the trend of the number of lung cancers and of tobacco consumption are
parallel but 20 to 30 years apart. This difference corresponds to the 'induction period' for lung
cancer.
Attention has also been focused in recent years on the effects on health of the involuntary inhaling of
tobacco smoke, or 'passive smoking'. Clear trends are now emerging which show that smoking
damages not only the smoker's health but also that of people who, like it or not, live or work in an
atmosphere filled with tobacco smoke. Thus, a year ago, the Journal of the American Medical
Association (May 1985 issue) noted 14 epidemiological studies on this theme in the United States,
(J) R. Doll and A. B. Hill, Smoking and Carcinoma of the lung, British Medical Journal, 2, pp. 739—48,
1950.
(2) International Agency for Research on Cancer, Monographs on the Evaluation of the Carcinogenic Risk of
Chemicals to Humans: Tobacco Smoking. Volume 38, Lyon, France, 1986.
(3) R. Roemer, L'action legislative contre I'epidemie mondiale de tabagisme, WHO, Geneva, 1983.
No C 50/10 Official Journal of the European Communities 26. 2. 87
Relationship between the frequency of lung cancer morality and the number of cigarettes smoked per
day in different prospective studies
X 35
X30
X25
X20
Increase in frequency of deaths
from cancer of the lung
X 15
X 10
xs
1
0 10 20 30 40
Number of cigarettes smoked per day
Source: M. Tubiana, Le cancer, Presses universitaires de France, Paris, 1985.
Japan, Federal Republic of Germany, Greece and other countries. Thirteen of them conclude that
non-smokers run a far greater risk of lung cancer if they are exposed to cigarette smoke at home or at
work. In an oral communication at the International Cancer Congress, in Budapest in 1986, Sir
Richard Doll even went so far as to estimate that between one-quarter and one-third of all lung cancer
in non-smokers was caused by passive smoking.
So there is no longer any doubt that smoking is by far the most widespread carcinogenic agent in our
environment. Therefore, in the unanimous view of oncologists throughout the world, nothing would
more effectively reduce cancer deaths in Europe than cutting tobacco consumption. Furthermore,
such an action would contribute considerably to a reduction in the incidence of cardio-vascular
diseases.
2. Actions planned from 1987 to 1989
The fight against smoking will be a long-term affair, perhaps lasting a generation, as it would be
unrealistic to think that all smokers could be persuaded to give up their habit in the immediate future.
But the European Community does have some trump cards. Judicious use of the specific powers in
relation to the internal market, to the common agricultural policy, or to the protection of consumers,
will reinforce national, public or private actions in the fight against tobacco. For clarity, the
Community actions foreseen from 1987 to 1989 have been regrouped according to the main fields of
competence of the European Community. Therefore, these actions are not placed in any order of
priority.
Q Great Britain
Male smokers
USA
26. 2. 87 Official Journal of the European Communities N o C 50/11
A. The internal market and tobacco
The Member States of the European Community are committed to finally setting up a true common
market by the end of 1992. In particular this will involve bringing their taxation systems into line, so
that they can eliminate the frontier checks which are still necessary today owing to the wide range of
taxation systems in Europe. Manufactured tobacco is a textbook example of this, as shown in Table
2, since the tax on an ordinary packet of 20 cigarettes varies form 0,26 ECU in Greece to 2,76 ECU in
Denmark.
The high level of taxation in the latter country, which is a record for Europe, if not the world, is based
on the intrinsic nature of the Danish taxation system. The Danish health and social security systems
are financed not by deducting social security contributions from wages, but mainly by direct or
indirect taxation.
Table 2
Retail prices and tax on the most common packets of 20 cigarettes in each country in April 1986
(ECU)
Retail price
Tax
Retail price
Tax
Denmark
3,16
2,76
Italy
1,02
0,73
Ireland
2,54
1,88
Luxembourg
0,97
0,65
United
Kingdom
2,35
1,76
France
0,68
0,51
Germany
1,77
1,30
Portugal
0,73
0,50
Nether-
1,36
0,97
Spam
0,73
0,38
Belgium
1,24
0,87
Greece
0,43
0,26
In view of public health requirements, steps should obviously be taken to ensure that the
harmonization of excise duties and taxes on tobacco does not lead to a drop in prices in countries with
the heaviest tax burden. This suggests that taxation should therefore be aligned with the higher rates.
On the basis of this principle, account should nevertheless be taken of the wide disparity of the starting
situations — a factor of 10 between the Greek and Danish rates — and, accordingly, to make very
gradual changes in the run up to 1992 to enable all the parties concerned to adapt, by setting a
sufficiently wide harmonization bracket, without ruling out the possibility of temporary exception
clauses.
Proposed action 1: Upwards alignment of taxation on tobacco manufactured in the European
Community
By 1 April 1987, the Commission of the European Communities will send the Council proposals for
directives for adoption by the end of 1987, concerning the common brackets to be adopted for the
main excise duties and value added tax, including those relating to manufactured tobacco.
These proposals dealing with approximation of fiscal measures on manufactured tobacco could lead
to a general reduction in tobacco consumption and, as a consequence, to an improvement in
Europeans' well-being and health. In this respect, the Commission of the European Communities is
inviting the Member States to begin the necessary fiscal changes beginning from 1987.
In most European countries, these fiscal measures would lead to an increase, sometimes very
substantial, in tax revenue. Indeed, experience has shown that demand for cigarettes falls slightly
when prices rise. Several studies carried out in the United Kingdom and other European countries have
demonstrated that a given percentage increase in price (e.g. 10 %) is followed by a reduction by half
this percentage in tobacco consumption (5 % reduction in this case). This ratio of 0,5 between the
variation in the price and the consumption has been observed for small price increases.
N o C 50/12 Official Journal of the European Communities 26. 2. 87
Proposed action 2: Financing of preventive actions at national level by the use of increased fiscal
measures on tobacco
In 1987, the Commission intends to submit to Council proposals aimed at improving the present
situation as concerns the detection and early diagnosis of certain cancers (see Chapter IV). It is evident
that in the majority of countries, the financing of these programmes will be facilitated by the increase
in taxes which will result from the upwards alignment of taxation on tobacco manufactured in the
European Community.
This upwards alignment of taxation will result in other respects in an increase in the retail price of
manufactured tobacco. It is evident that this increase should not be taken into account in wage
' negotiations. In order to make the effects of these tax changes more clear to the public and to the social
partners, it is appropriate to publish the cost of living indices without manufactured tobacco. These
indices could therefore be made reference to, when Member States are carrying out wage
negotiations.
Action 3: Publication of indices excluding tobacco by the Statistical Office of the European
Communities
Starting in 1987, the Statistical Office of the European Communities will publish regularly, for each of
the 12 Member States, a price index excluding manufactured tobacco.
Of course, these price increases in manufactured tobacco are only one of several elements which have
to be used in the fight against tobacco which is the most widely spread carcinogenic substance with
which we are faced in our everyday surroundings.
Proposed action 4: Harmonization of cigarette labelling in the European Community
Before the end of 1988 the Commission will be submitting proposals concerning the labelling of
cigarettes and other products derived from tobacco in order that a health warning and exact details of
the composition of the contents will appear on every package.
In this respect, it is now an established fact that the lower the tar content of the tobacco smoked, the
less the risk of lung cancer to the smoker. To encourage smokers to change to low-tar brands, the
introduction of a tax proportional to tar content has been proposed at times. Such an approach seems
much more difficult to put into practice than purely and simply prohibiting certain categories of
manufactured tobacco and derived products.
Proposed action 5: Prohibition of cigarettes with a high tar content
Before theend of 1987 the European Commission will submit a proposal to the Council for a Directive
to prohibit cigarettes with a tar content above a certain level in all Member States.
In order to permit industry — and smokers — to adapt to such a measure, these values will have to be
well chosen. By way of illustration, the maximum values could be 15 milligrams per cigarette in 1989
and 12 milligrams in 1992. It is evident that some Member States of the European Communities may
wish to go both further and more quickly with such measures. In addition, for this action and the
previous one to be fully effective, it will also be advisable to harmonize the methods of measurement
for these substances.
Proposed action 6: Harmonization of the standards for the components of tobacco smoke
In 1987 the Commission will have comparative tests carried out on the different standards used for
determining the composition of cigarette smoke, with a view to proposing the establishment of a
common standard to the Council in 1988.
Furthermore, artificial incitements to smoke which still exist by tradition here and there should be
done away with quickly, whether they concern the distribution of free or cheap tobacco to young
people serving in the armed forces or the sales of duty-free tobacco at ports and airports. If the former
type of prohibition is an affair for the Member States, the latter falls directly within the competence of
the European Community. There is, incidentally, already a prohibition of this kind in force in relation
to travel within the Benelux countries.
26. 2. 87 Official Journal of the European Communities No C 50/13
Proposed action 7: Prohibition of tax-free sales of tobacco in the European Community
Before the end of 1988, the European Commission will transmit to the Council a proposal for a
Directive to prohibit tax-free sales of tobacco in the European Community.
New products such as chewing tobacco have recently been placed on the market, notably in the United
States. By their presentation and publicity, these products often have great attraction for adolescents
and children. Some of these contain a high level of nicotine. Their use therefore has every chance of
setting up a dependence on nicotine and accordingly on tobacco. Some countries, such as the United
Kingdom, have adopted measures to protect against these new products. Thus, in July 1986 in the
Protection of Children (Tobacco) Act, the sale of tobacco and all derived products to children under
16 is forbidden irrespective of the person to whom the products are intended. Ireland has totally
banned certain chewing tobaccos, such as Skoal Bandits which originates from the United States.
Proposed action 8: Protection of children from tobacco sales
In 1987 and 1988 the Commission of the European Communities will be transmitting proposals to the
Council and the European Parliament aimed at prohibiting the sale of tobacco and derived products to
children.
B. Agriculture and tobacco
The situation as regards the tobacco sector in the European Community can be summed up by the
following economic data. There are, at present, just over 230 000 producers based mainly in the least
favoured regions, where unemployment is highest. Downstream, some 1 800 000 persons are
employed — in most cases on a full-time basis — in the processing and marketing sectors (1). In
addition, the European Community imports more than half of its requirements, with the result that it
was faced with a trade deficit of almost 2 000 million ECU in 1985.
Inevitably, any policy which aims to reduce, in the short term, the European production of tobacco
will also have an impact on employment in those areas already affected, as well as increasing the trade
deficit which is already large. Quite clearly, the policy pursued in this sector will need in future to take
more account of the health aspects.
Proposed action 9: Reorientation of tobacco production towards less toxic varieties and study of the
possibilities of reconversion
With effect from 1987, the Commission will ensure that action is taken to step up the rechannelling of
production towards the varieties of tobacco which are most in demand and which are also least
injurious to health. In parallel, the reconversion possibilities to other activities will be examined, in
particular as concerns the production of fruit and vegetables which have a beneficial role to play in the
prevention of cancer.
To this end, it will act on the price guarantees to tobacco producers and on the premiums paid to
Community tobacco buyers. These buyers — who are either local firms, national monopolies, or
multinational firms — received about 800 million ECU in 1986 from the European Community.
This amount may at first sight seem enormous when compared with the annual budget which the
European Community allocates to medical research (about 10 million ECU per year), but such a
comparison really makes no sense. On the one hand, at this stage in the process of European
integration, medical research remains for the most part a national prerogative, and the Community
budget represents no more than 1 % of the total of national spending in this field.
On the other hand, the common agricultural policy is, at present, one of the few policies that is
integrated at European level such that the corresponding payments are not made by the Member States
but by the European Community. Without doubt, even if the common agricultural policy did not
exist, national premiums of this order of magnitude would still be paid to the tobacco sector, in one
form or another. As proof, it has been estimated that, for example, in the United States more than two
billion dollars aid is paid to the tobacco sector.
This paradoxical situation, whether European or American, remains very much a reality. After five
centuries of tobacco use, it is not so easy to get rid of it in a few years.
In parallel with this action to reduce tobacco production, there is also a requirement to reduce the
consumption of manufactured tobacco in the European Community, in order to avoid a worsening of
(!) The tobacco industry in the European Community, PEIDA Report, Edinburgh, 1985.
No C 50/14 Official Journal of the European Communities 26. 2. 87
the balance of payments, which is already in serious deficit. At the time, account will be taken of
tobacco importations, having regard to existing international agreements. In addition to this
economic argument there is the requirement to fight against this agent which is the most widely spread
carcinogen with which we are faced in our everyday surroundings, and which causes about one-third
of the deaths from cancer.
Proposed action 10: Information and public awareness campaign in the struggle against tobacco
In the period 1980 to 1989 this action will be carried out in the European Community and directed
towards the general population, teaching staff and health care workers. This public awareness
campaign will reach its peak in 1989 with the 'European information on cancer year' (see Chapter 2).
The cost of this action for the Community budget will be less than that arising from the savings made
as a result of the reduction of the premiums paid to the Community tobacco buyers. As an example, a
reduction of 1 % in these premiums represents about 8 million ECU. This is therefore somewhat of an
indirect contribution of the tobacco sector to the campaign against cancer.
C. Protection of consumers and workers
In view of the dangers posed by passive smoking and given the need to reduce direct and indirect
tobacco advertising as much as possible, it will fall to the responsible national authorities and the
Community institutions to promote appropriate measures.
Proposed action 11: Study of national provisions, and development of proposed Community
regulations on tobacco smoking in public places
Before the end of 1988, the Commission will be transmitting to the Council a proposal for the control
of tobacco smoking in public places and at work.
Those proposals will be carried out after a study has been performed on the national measures
governing tobacco smoking in public transport, in buildings open to the public, and at the workplace.
The experience acquired by countries outside the European Community will also be taken into
account.
Proposed action 12: Study of national provisions, and development of proposed Community
regulations on the limitation of tobacco publicity
Before the end of 1989, the Commission will transmit to the Council proposals seeking to prohibit
direct advertising and to curb indirect advertising as much as possible, and in particular the sponsoring
of sporting events.
In addition, it will be recommended that expenditure on tobacco advertising should not be
tax-deductible for the companies concerned and that the resulting increase in tax revenue be
earmarked for the financing of information campaigns on the dangers of tobacco.
D. Exchange of experience
All the countries concerned have already been involved, over varying periods and with varying degrees
of determination and success, in public information campaigns and efforts to discourage the use of
tobacco.
Action 13: Comparative analysis of anti-smoking campaigns
In 1987 the Commission will make an evaluation of existing measures designed to help smokers to give
up the habit and will encourage the widespread application of those measures that have proved
successful throughout the period 1987 to 1989.
Action 14: Information exchange in the struggle against smoking
The Commission will also promote, from 1987, exchanges of information and experience on the
strategies to combat smoking that have been conducted both inside and outside the Community.
If these 14 proposed actions are implemented, there is no question but that the European Community
would be making a major contribution to the struggle against the scourge of smoking. As from 1988,
an evaluation of the impact of these actions will be regularly undertaken, in particular, by means of
'Eurobarometer polls' (see Chapter 2). Furthermore, these measures will also be added to by other
proposals in the field of information and health education of young people and adults. These points
are also dealt with in Chapter 2.
26. 2. 87 Official Journal of the European Communities N o C 50/15
II. IMPROVEMENT IN NUTRITION
1. Nutrition and cancer
Many factors indicate that eating habits, including the consumption of alcohol, are of considerable
importance in the induction and also prevention of several common types of cancers in men and
women, such as cancer of the digestive tract — from the mouth to the rectum — and breast cancer. In
the study mentioned earlier, Doll and Peto estimate that in the United States nutritional factors could
be involved in more than one-third of human cancer deaths. However, the authors themsleves admit
that this evaluation is not at all accurate since the margin of uncertainty ranges from 10 to 70 % (x),
contrasting with their estimates on the role of tobacco, where the range of 25 to 45 % is very much
narrower.
There is unusual unanimity amongst oncologists on the relationship between tobacco and cancer but
this is not the case with regard to the links between nutrition and cancer. Caution is still called for in
this field where the precise role of numerous nutritional factors is often still unclear. However, the
available research permits a few important observations to be made. From the point of view of
preventing cancer, the conclusions that can be drawn are fortunately comparable with those required
to reduce cardio-vascular diseases. The task of those responsible for public health is therefore
facilitated.
1. In several European countries an excessive intake of alcoholic beverages on their own are the
second most important cancer risk factor after tobacco. In a country like France which has the
highest per capita consumption in the world, one cancer in 10 is thought to be linked to excessive
alcohol consumption. Although ethanol in itself is not carcinogenic, it has been found that certain
other components of alcoholic beverages sometimes are. Also, no doubt because of the chronic
irritation it causes, it leads to a marked increase in the frequency of cancer in the mouth, throat
and oesophagus especially when the drinker also smokes. In France, for example, the frequency of
cancer of the oesophagus in persons who smoke fewer than 10 cigarettes a day and who drink less
than 40 grams of ethanol a day, is 20 times lower than in non-smokers who drink a litre of wine
per day (80 grams of ethanol), and it is 44 times lower than in persons who smoke 20 cigarettes a
day and who drink a litre of wine a day (2).
2. In contrast to an excessive intake of alcohol, for which there is no longer any doubt about its
harmful effect in the development of cancer (see Table 3), there is now sufficient evidence that
fresh fruits and vegetables play an important but protective role for certain cancers. For example,
E. Wynder and H. T. Goodman (3) convincingly demonstrated that high consumption of fresh
fruits and vegetables, which include the major sources of vitamins A and C, protects against lung
cancer, although recent results are suggesting that the protection does not appear among the
heaviest smokers (two or more packets daily). There is also evidence that fresh fruits and
vegetables protect against the risks of cancers of the oesophagus, stomach, pancreas and colon
(see Table 3).
3. The overweight seem also to be at greater risk, especially women, as shown by an American study
covering 750 000 people over 13 years (4). For some cancers such as those of the gall bladder and
body of the uterus (endometrium), mortality rates for people who were 40% overweight were
more than four times higher than the mean. In connection with the possible relations between
excessive weight and mammary cancer in post-menopaused women, F. de Waard (s) reports that a
statistical correlation was confirmed in 22 of the 27 studies listed.
4. At present the specific role of each of the different types of fat still has to be elucidated. Several
epidemiological studies nevertheless seem to indicate that, as in animals, an excessively fatty diet
(*) This applies only to food products in the strict sense of the term, i.e. excluding alcohol and food additives (see
Table 1).
(2) A. Tuyns, International Agency for Research on Cancer, Alcohol and Cancer, Lyon, 1978.
(3) E. Wynder and M. T. Goodman, Smoking and lung cancer; some unresolved issues, Epidemiological Reviews,
• 5, pp. 177—207, 1983.
(4) EA Lew, L. Garfinkel: Variations in mortality by weight among 750 000 men and women, Journal of
Chronical Disease, 32, pp. 563—76, 1979.
(5) F. de Waard, Dietary fat and mammary cancer, Nutrition and Cancer, Vol. 8, No 1, pp. 5—7, 1986.
No C 50/16 Official Journal of the European Communities 26. 2. 87
leads to, in particular, an increased risk of mammary and colon cancer. This observation is all the
more important because these diseases are responsible for a high proportion of deaths from cancer
in Europe and the United States (*). It also appears that an excessively fatty diet may be associated
with cancer of the pancreas, but this hypothesis has still to be confirmed.
5. The importance of dietary fibre for intestinal function has long been known. However, it was not
till 1971 that Burkitt a British military surgeon (2) reported on a possible link between a low-fibre
diet and the incidence of cancer of the colon. Although there was considerable controversy about
this hypothesis, it is now beginning to be accepted, especially since it has been confirmed by more
recent studies using modern techniques to measure the fibre content of foodstuffs (3).
6. Other elements consumed in small quantities, often quite accidentally, may also influence the
onset of certain human cancers. Some of the mycotoxins produced by moulds, such as the
aflatoxins, have proved to be carcinogenic in animals.
According to the work performed by the International Agency for Research on Cancer (IARC) (4),
we cannot, either, overlook the possible role of nitrites and perhaps also under certain conditions,
nitrates. Present in the form of residues in drinking water and vegetables, and used as preservatives
in certain meats and sausages, these nitrogen compounds may be converted, under conditions that
still have to be clarified, into N-nitriso compounds in the stomach, which are highly carcinogenic
in animals.
In addition, some food additives which have proved carcinogenic in animals such as butter yellow
are today prohibited. According to Doll and Peto, less than 1 % of all cancer deaths might
originate form harmful food additives. Their margin of uncertainty ranges from - 5 to 2 %, the
negative lower border indicating that some of these additives might also help to prevent cancer. In
particular, the antioxidants which have improved the preservation of foods appear to have played
some part in the spectacular reduction in the number of stomach cancers.
7. Finally, J. V. Joosens (s) suggested in 1980 that too much salt in food could increase the risk of
stomach cancer. These initial results are contested and still have to be confirmed.
In summary, nutritional factors can play an important role, either in the production or in the
prevention of certain cancers. Nevertheless, an estimate of the cancer burden which can be confidently
attibuted to individual dietary constituents cannot yet be precisely determined because of the relatively
small number of epidemiological studies performed. In Table 3, estimates are presented of the
frequency of involvement of alcohol, fruit and vegetable and obesity in certain types of cancers, based
on studies in European, Australasian and North American population groups. This list is not
exhaustive; it is not possible to complete it at present with associations such as between excessive fat
intake and prostate cancer, and insufficient vitamin intake and bladder cancer, as these and other
dietary constituents cannot be assessed due to there being only a few studies available. Further, the
association with total caloric intake and the risk of certain cancers has proved difficult to evaluate for a
variety of reasons, including the problems of measuring total caloric intake in individual cases.
Obviously further research is necessary to clarify the possible relationships between food and cancer.
Some European research programmes are already working along these lines and will continue to do so
(see Chapter IV). At this stage, however, it is possible to make use of the available results, despite
uncertainties still hovering over some of them, in deciding on the actions to be taken over the period
1987 to 1989.
(') K. K. Carroll, Dietary fat and cancer, Nutrition and Cancer, Vol. 8, No 1, pp. 3—5, 1986.
(2) D. P. Burkitt, Epidemiology of cancer of the colon and rectum, Cancer, 28, pp. 3—13, 1971.
(3) Health nutrition: preventing nutrition-related diseases in Europe, World Health Organization, July
1986.
(4) H. Bartsch and R. Montesano (IARC), Relevance of nitrosamines to human cancer, Carcinogenesis, Vol. 5,
No 11, pp. 1381—93, 1984.
(5) J- V. Joosens, Stroke, stomach cancer and salt: possible clue to the prevention of hypertension?, in
Epidemiology of Arterial Blood Pressure, The Hague, Nijhoff, pp. 489—508, 1980.
26. 2. 87 Official Journal of the European Communities No C 50/17
Table 3
Frequency of involvement of nutritional factors in certain types of cancer
Dietary factor
A L C O H O L
FRUIT A N D VEGETABLES
(including vitamins)
Diet low in fruit and vegetables
Diet low in fruit and vegetables
Increase in vitamin C by 100 m g / d a y
Diet low in fresh fruit
Diet low in fresh fruit
(probably vitamin A)
Diet low in fresh vegetables
OBESITY
Type of cancer
Mouth
Oesophagus
Larynx
Liver
Oesophagus
Stomach
Stomach
Pancreas
Lung
Colo-rectal
Breast
Body of the uterus
(endometrium)
Prostate
Nutritional factor present
in the following frequency
75 % in conjunction with cigarette
smoking
4 0 % alone
70 % in conjunction with cigarette
smoking
25 % alone
30 to 65 % in conjunction with cigaret-
te smoking
1 5 % (more than 30 grams
ethanol per day)
4 0 % (more than 370 grams
ethanol per day)
15 to 5 0 %
7 0 %
55 instead of 70 %
1 5 %
2 0 %
20 to 40 %
0 t o l 2 %
20 %
2 0 %
Source: Provisional document of IARC.
2. 1987 to 1989 actions
The success of a policy designed to improve nutrition and health will depend on the cooperation of a
large number of participants, namely, consumers and their representative organizations, the teaching
and medical professions, farmers and agri-foodstuffs businesses, restaurants, national authorities and
the Community institutions. The latter have important, specific powers in relation to the management
and adaptation not only of the common market in industrial products, but also in the common
agricultural policy.
Clearly, however, sufficiently explicit guidelines addressed to each of these many participants would
be required in order to ensure adequate mobilization of their energies, and it is appropriate to prepare
guidelines that are clear, as well as being adapted to each case.
A. Elaboration of guidelines relating to nutrition and cancer prevention
Attempts to draft such guidelines have already been made by several expert committees throughout
the world. For example, the National Cancer Institute (J) in the United States in 1982, or again in the
European context the European Organization for Cooperation in Cancer Prevention Studies
(ECP) (2) (3). These nutritional recommendations will naturally be carefully studied and improved as
far as possible.
i1) Cancer control — objectives for the nation: 1986 to 2000, National Cancer Institute, Washington, 1986.
(2) ECP symposium, Diet and human carcinogenesis, Elsevier Science Publishers, Amsterdam, 1986.
(3) Proceedings of a joint ECP — IUNB workshop on diet and human carcinogenesis, Nutrition and Cancer,
1986.
No C 50/18 Official Journal of the European Communities 26. 2. 87
Action 15: Analysis of existing information on 'nutrition and cancer'
The numerous data available concerning the relationship between nutrition and cancer will be
collated before the end of 1987.
To this end, the Commission intends to exploit and coordinate the expert knowledge already available
within the committees and consultative groups which advise it on nutrition; it will also consult other
competent international bodies such as the 'European Organization for Cooperation in Cancer
Prevention Studies' (ECP) or the 'International Agency for Research on Cancer' (IARC).
Action 16: Development of nutritional recommendations against cancer adapted to each of the
categories of participants concerned
At the same time, efforts will be made to draw up specific recommandations which could be addressed
to the different categories of participants concerned: consumers and their representative
organizations, the teaching and medical professions, farmers and agri-foodstuffs businesses, and the
catering sector.
Clearly, these guidelines must be adapted so as to be relevant to each category, although the wealth of
regional and national diversity within the Community must always be respected. By way of example,
and exclusively on the basis of the observations set out above, a number of major nutritional principles
to be addressed to consumers and the teaching and medical professions can be formulated: avoid
excessive alcohol consumption, avoid being overweight, eat low fat foods, eat fresh fruit, vegetables
and cereals rich in dietary fibre (see below, the European code against cancer).
B. The common market and nutrition
In the agri-foodstuffs sector, Community provisions designed to protect the health of consumers have
been in force for a considerable length of time. For example, since 1962 only those food additives
appearing on a list approved by the Council of Ministers based on a Commission proposal, following
consultation of the 'Scientific Committee on Food' may be used in the Community. The following new
actions are to be initiated as from 1987.
Proposed action 17: Harmonization of nutritional labelling of foodstuffs in the European
Communities
In 1987, the European Commission will submit to the Council a draft Directive harmonizing the
presentation of nutritional information to be placed on the packaging of foodstuffs.
Proposed action 18: Consumer protection against certain agents in foodstuffs
The results of research underway on 'nutrition and cancer' could lead the Commission to submit to the
Council new proposals designed to provide the public with greater protection against certain
potentially carcinogenic agents (mycotoxins, chemical substances, etc.).
C. Agriculture and consumer protection
Farmers and, consequently, the common agricultural policy play a central role in the strategy aimed at
responding more effectively to the nutritional and health concerns which are being voiced by
consumers and the medical profession. The following projects are to be implemented in the period
1987 to 1989.
26. 2. 87 Official Journal of the European Communities N o C 50/19
Action 19: Improvement of existing information campaigns concerning nutrition
As from 1987, existing information and publicity campaigns fn respect of certain foodstuffs will be
modified in order to take greater account of the latest research findings concerning the links between
nutrition and health.
As an example, publicity campaigns for dairy products should be better oriented towards the target
groups which have been selected. Whole milk can undoubtedly be recommended for young children.
As concerns adults, they should be directed in the majority of cases towards low-fat dairy
products.
Action 20: Initiation of information campaigns for recommended foodstuffs
New information and publicity campaigns in respect of foodstuffs which are potentially beneficial to
health on the basis of the nutritional guidelines will be drawn up as from 1987.
Such projects can be envisaged in the case of fruit and vegetables. The success of these campaigns will
be all the greater if they can be integrated into an overall effort designed to increase the awareness
not only of the general public but also of school and university students and teachers (see
Chapter 2).
Proposed action 21: Promotion of appropriate foodstuffs and techniques
In the light of these most recent nutritional findings, attempts will be made within the context of the
common agricultural policy to promote the production conditions and foodstuffs considered most
suitable from the public-health standpoint.
Two types of action could be considered:
— legislative amendments designed, for example, to modify existing requirements relating to butter.
Currently the designation 'butter' cannot be used unless it contains a high level of fat (minimum
80 %) . In the future the designation 'butter' should be extended to butter with a lower fat content,
which is more appropriate to adult nutrition. Of course to be allowed to use this label, this butter
must be produced exclusively from milk,
— the promotion of production methods using existing techniques to the best of our knowledge so as
to reduce the utilization of certain chemical products, as for example in the concentration of
nitrates and nitrites in vegetables.
At this stage, these different examples can have no more than an illustrative character. Nevertheless
they give some idea of the importance of this field of action which is opening up for the common
agricultural policy.
D. Exchanges of information and experience concerning nutrition
Pilot projects in the nutritional field are in progress in certain areas, particularly in Italy, Netherlands
and Sweden. They involve participants at the local level (retailers, the agri-foodstuffs industry,
consumers, schools). Their main purpose is to test the effects of nutritional information and health
education programmes.
Action 22: Evaluation of pilot experiments in nutrition
These pilot experiments will be evaluated and their results disseminated in due course. The
Commission could promote further pilot projects in other parts of the Community, if this proved
appropriate.
Action 23: Exchange of information on 'nutrition and cancer'
As from 1987, the Commission will ensure a regular exchange of information on the results of studies,
research and experiments relating to 'nutrition and cancer' by means of seminars and conferences,
which will also be open to experts from non-member countries, and by the extensive, though selective,
dissemination of the results obtained.
It will obviously be necessary to supplement, clarify or expand these nine actions, which are designed
to improve nutrition within the Community in an attempt to prevent cancer, as new, reliable data
become available. Even at this stage, it is right to consider that they will make a significant, if modest,
contribution to the fight against cancer. Furthermore, they also have a role to play in improving the
prevention of cardio-vascular diseases.
26. 2. 87 Official Journal of the European Communities No C 50/25
III. PROTECTION AGAINST CARCINOGENIC AGENTS
1. The diversity of carcinogenic agents
According to Doll and Peto, tobacco, alcohol and diet, taken together, are the causes of more than
two-thirds of deaths from cancer. The remaining third results from other factors present in our daily
environment, in particular radioactivity and ultraviolet radiation, viral infections, and chemical
substances.
A. Radioactivity and ultraviolet radiations
The accident of the nuclear reactor of Chernobyl has drawn attention to the risks arising from ionizing
radiation.
All humans are exposed constantly to radiation as a result of cosmic radiation and from
radio-elements present in the soil and in foodstuffs. To this natural dose of radiation has to be added
the dose resulting from human activities which gives rise to a similar level of exposure. The mining and
milling of uranium and other radioactive ores, the nuclear energy industry, with their radioactive
wastes result, on average, for the populations of those countries in which nuclear energy is developed,
in a dose which is far below that resulting from natural radiation.
In fact, 80 % of the dose received from human activities is due to medical uses of ionizing radiation,
essentially radio-diagnosis. Continued efforts have been made in this sector to reduce the doses
resulting from medical sources. In particular, there has been recently considerable progress in the
reduction of doses resulting from radio-diagnosis, as for example in mammography (breast
X-ray).
There has been a recent addition to this background radiation as a result of the radioactive isotopes
released into the atmosphere by the Chernobyl accident. In Western Europe, there is generally less
than a hundredth of the annual dose received from natural radiation. It is about one-tenth of the
natural radiation of Central Europe. By way of comparison, the radiation resulting from Chernobyl
is, in Western Europe, less than a hundredth of the dose due to the radiation fallout resulting from the
experimental atomic explosions in the 1950s and 1960s. The consequences for human health are
likely to be extremely limited. It should be remembered that Doll and Peto estimated that less than 1 %
of cancers were due to ionizing radiation.
Among non-ionizing radiations, ultraviolet rays are carcinogenic. They are present in sunlight.
Ultraviolet rays can cause skin cancer as a result of irradiating the germinal epithelium. This has been
observed, in particular in persons with white skin. Ultraviolet rays are therefore responsible for a high
proportion of basal and squamous cell cancers which are easy to treat and cure. Ultraviolet sunlight is
also incriminated in the causation of malignant melanomas, cancers of a serious nature, which are
difficult to treat and for which the frequency is increasing regularly in certain populations (Australians
for example) whose skin is very white and who are frequently exposed to sunlight. The most
dangerous exposures are those which occur when the skin is not tanned, and therefore does not filter
out the sun rays. For this reason, it is generally advised to avoid prolonged and over exposures to the
sun in those persons who have white skin, and in these cases it is recommended that creams are used
which filter out the ultraviolet light.
B. Viruses
It has now been proved scientifically that viruses play an important role in the development of human
cancer resulting from the work of the American Robert Gallo, and of other Japanese scientists, who
demonstrated at the beginning of the 1980s, the essential role of the HTLV (humans T-cell leukaemia
virus) retrovirus in the development of a type of leukaemia observed above all in Japan and in the
Caribbean. In addition, for many years, a small number of viruses have been suspected of being
implicated in the development of certain cancers. A well-known case is that of the hepatitis B virus
which is associated with an increased risk of liver cancer in those persons who have had viral hepatitis,
most of all in Africa where aflatoxin may be a determining cofactor.
No C 50/26 Official Journal of the European Communities 26. 2. 87
Furthermore, the German, Zur Hausen, at Heidelberg has demonstrated that many genital lesions are
associated with the papilloma family of viruses. Certain of these could be at the origin of cancer of the
uterine cervix, in particular, the papilloma-virus 16 which is found in more than half of these cancers.
Here again, further research is required not only to clarify the possible role of cofactors but also, in the
longer term, to develop vaccines. Nevertheless, in the short term, simple preventive measures in the
field of sexual hygiene can be recommended.
C. Chemical substances
Thanks to Sir Percival Pott, we have known for two centuries, that certain chemical substances in our
environment can cause human cancers. It is a somewhat remarkable fact that the rise of the industrial
revolution over the past two centuries which has been accompanied by an explosion of new chemical
substances, leading to an increase in the exposure both of workers and of the general public to these
substances, has not resulted in an epidemic of cancers. Furthermore, thanks to the cancer registers
which have been present in some industrial countries for almost 50 years, and to the epidemiological
studies carried out throughout the world, only a few hundreds of chemical substances — of the
100 000 in the European inventory of existing chemical substances — have been shown to be
carcinogenic. It is important to underline that international cooperation in this field has been
fruitful.
It was in 1965 that General de Gaulle, then President of France, proposed that the major countries
devote a small portion of their military budget to the creation, under the auspices of the World Health
Organization, of the International Agency for Research on Cancer (IARC). Now installed in Lyons,
France, IARC has evaluated since 1971, the carcinogenic risks of chemical substances, and of certain
mixtures for humans.
Of 107 substances, mixtures of substances, or industrial processes for which there is epidemiological
data, 39 are considered to cause cancer in humans, and 68 others probably do so (!).
An increasing number of other chemical substances, for which there are insufficient epidemiological
data, are the subject of tests in animals. According to IARC, in September 1986, 127 of these were
carcinogenic in animals, and as such are suspected of being carcinogenic for humans.
Finally, it has been found that a large proportion of chemical carcinogens also induce mutations in the
genomes of bacteria or animal cells. This finding is of great practical significance as it provides a direct
possibility, by means of simple and rapid assays, to obtain information on which substances are likely
to be carcinogenic. Most of the substances currently on the market could therefore be screened in this
way.
It is evident that the work of evaluating the mutagenicity and carcinogenicity of chemical substances
should be speeded up throughout the world. It is also appropriate to use the results of work already
performed in order to determine if these substances can be used, and in what conditions.
(a) H. Vainio, K. Hemminki, J. Wilbourn (CIRC), Data on the carcinogenicity of chemicals in the IARC
monographs, Carcinogenesis, Vol. 6, No 11, p. 1653, 1985.
26. 2. 87 Official Journal of the European Communities No C 50/27
2. Actions foreseen from 1987 to 1989
A. Euratom Treaty and protection against ionizing radiations
The Euratom Treaty has a fundamental task of the European Atomic Energy Community to 'establish
uniform safety standards to protect the health of workers and of the general public, and to ensure that
they are applied'. These maximal standards for radioactivity were established for the first time in
1959, and have been modified several times since then. Furthermore, in 1984, a Community Directive
was adopted for the protection of persons against radioactivity resulting from medical examinations
or treatment.
Proposed action 24: Protection against ionizing radiations and follow-up to Chernobyl
During the period 1987 to 1989, several actions are foreseen, in particular: a review of emission
standards for nuclear power stations; the establishment of maximal limit values for the radioactive
contamination of foodstuffs; the elaboration of additional protection measures for the protection of
workers in nuclear power stations.
In addition, a feasability study on the evaluation of effects of natural radioactivity is foreseen within
the context of the research programme on radioprotection (see Chapter 4).
B. Protection of workers and consumers against carcinogenic chemical substances
Since 1984 the Commission has been undertaking the classification and labelling of chemical
substances likely to be carcinogenic. The optimal conditions of use of these substances are then
subsequently determined, either by the Commission, or by the Council, depending on the case.
Nevertheless, the Community did not wait until 1984 to establish a certain number of Community
Directives on the protection of workers, as for vinyl chloride monomer (1978) and asbestos (1983).
For the protection of consumers other Directives have introduced a ban on the marketing of vinyl
chloride monomer used as a propellant in aerosols (1976) and certain flame retardants used in
children's clothing (1979, 1983).
It is essential to speed up the work at Community level of classification and labelling, as well as the
determination of the optimal conditions of use of the carcinogenic substances thus classified.
Action 25: Creation of an observation antenna and establishment of a list of chemical substances
suspected of being carcinogenic
As from 1987, an observation antenna will be created within the Commission which will collect as
quickly as possible the data on suspected substances.
It will establish appropriate contacts with relevant organizations, in particular IARC, with a view to
avoiding any duplication of work, and it will also draw up a Community list of substances to be
examined, as in the attached diagram.
Decisions on the classification and labelling of chemical substances are made by the Commission, with
the assistance of a national expert committee. Since 1984, this committee has been dealing with
suspected carcinogenic substances, and, by the end of 1986, only about 50 substances have been
classified and labelled with the warning 'can cause cancer'. It is therefore necessary to speed up the
work in this field.
Action 26: Speeding-up of the work at Community level, and creation of a special group on
classification and labelling of carcinogenic substances
The speeding-up as from 1986 of the work of classification and labelling of carcinogenic substances
will be continued in the years 1987 to 1989 in order to achieve 50 evaluations per year.
This means that by the end of 1989, about 200 substances will have been studied. In order to achieve
this, a special group 'classification and labelling of carcinogenic substances', will be set up within the
Commission.
In parallel, the Community will make decisions on the optimal standards of use of those
substances which are carcinogenic or suspected of so being, in order to improve the prevention of
No C 50/28 Official Journal of the European Communities 26. 2. 87
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26. 2. 87 Official Journal of the European Communities No C 50/29
occupational cancers and the protection of consumers. It is evident this is a delicate task in view of the
economic implications that could arise as a result of a decision to ban or to fix limit values for use. In
the latter case, the situation is complicated, as a result of the impossibility of carrying out experiments
on humans for the determination of thresholds for exposure (if any) and the choice is therefore as
much political as scientific. As a consequence, the corresponding decisions have to be taken after close
examination, but all the same there should not be unreasonable delays.
Proposed action 27: Adoption of Directives currently being discussed by Council for the protection of
workers (naphthylamine, aminodiphenyl, nitrodiphenyl and benzidine; benzene)
These two proposed Directives are currently being examined by Council, with a view to their being
adopted by 1987 at the latest. They concern substances which cause cancers of the bladder and bone
marrow (see Table 4).
Proposed action 28: New Directives for the protection of workers against carcinogenic
substances
The Commission will submit to Council, as from 1987, other proposals for Directives aimed at the
fight against occupational cancer. To this end, the list of 50 chemical substances already labelled by
the end of 1986 as causing cancer will be used. A group of substances will be dealt with at the same
time, and each Directive will establish the limit values relating to each substance. The work will be
completed as and when new substances are classified and labelled.
Proposed action 29: Prevention of occupational cancers by improving the practical organization in
undertakings, including information to employers and workers
By the end of 1988, the Commission will put forward proposals in this area, including those for small
and medium-sized undertakings. From 1987, appropriate information on the prevention of
occupational cancer will be drawn up and published.
Table 4
Examples of carcinogenic agents and industrial processes, and their effects on humans
Examples
CARCINOGENIC AGENTS
Asbestos
Aromatic amines:
— 4-Aminodiphenyl and its salts
— Benzidine and its salts
— 2-Naphthylamine and its salts
— 4-Nitrodiphenyl
Benzene
Bi-( chlormethyl )-ether
(Chlormethyl )-methyl-ether
Vinyl chloride
Zinc chromate
Arsenic trioxide
INDUSTRIAL PROCESSES
Underground haematite mining {l)
Isopropyl alcohol manufacture (')
Leather industry (tanning) (!)
Nickel refining (J)
Site of cancers
Lung, pleura, peritoneum
Bladder
Bladder
Bladder
Bladder
Bone marrow
Lung
Lung
Liver (angiosarcoma)
Lung
Lung, skin
Lung
Nose and nasal sinus
Nasal cavities
Lung, nasal cavities
(') The specific compound(s) responsible for a carcinogenic effect in humans have not yet been identified.
No C 50/30 Official Journal of the European Communities 26. 2. 87
Proposed action 30: New measures for public protection against carcinogenic substances
Finally, new proposals will be drawn up by the Commission, using the list of about 50 substances
which have been classified and labelled, which will define the optimal conditions of use of
carcinogenic substances, in particular within the context of the fourth programme on the protection of
the environment (1987 to 1992).
IV. SYSTEMATIC SCREENING AND EARLY DIAGNOSIS
1. Preliminary comments
The progress in these fields is so rapid that in the not too distant future, an ideal world may be attained
in which all types of cancer should be detected by screening and sufficiently early detection. Yet in
today's world this is far from true: on the one hand, for certain types of tumour there is no reliable
technique available, on the other hand, considerations of an economic nature cannot be avoided.
For certain sites, such as the colon or the uterine cervix, a cancer is often preceded by pre-cancerous
lesion: polyps in the colon, which can be detected by colonscopy, or pre-carcinogenic cells in the
uterine cervix, which can be found following a cervical smear. Systematic screening of the populations
at risk permits the exeresis of such lesions before the tumour develops.
For other sites, in particular the breast, it is possible to make an early diagnosis of the tumour, which
thus increases the chances of a successful outcome of treatment. Recent progress in medical
techniques, in particular mammography, has allowed earlier detection of such tumours.
A. Cancers of the uterine cervix
Certain countries in Europe and in North America have had screening programmes for cancer of the
uterine cervix since the 1940s. The method used is a cervical smear, called a PAP-test, after its inventor
the Greek biologist Georges Nicolas Papanicholaou (1883 to 1962) who developed it in 1941. The
International Agency for Research on Cancer (IARC) organized in November 1984 a workshop on the
evaluation of existing screening programmes for gynaecological cancer (*). The conclusion of this
collaborative study was that the degree of protection offered by mass screening for cancer of the
uterine cervix was 91 % for those aged between 20 and 64 years of age if it was carried out every year
or every three years. This degree of protection fell to 84 % if the screening was performed every five
years. The Committee of European Cancer Experts considered that at present, in view of the varying
stages of development in the Member States of the European Community, the following rule would
provide adequate protection: 'After the age of 20 to 30 have a cervical smear every 3 to 5 years'.
Nevertheless, there is recent evidence from certain countries, such as Denmark and the United
Kingdom, which suggests that there is an increase in the frequency of invasive cancers in younger
women aged between 20 to 35 years. This finding has led certain oncologists to think that there should
be a reduction in the age at which cervical screening begins.
B. Cancer of the breast
Cancer of the breast, according to the Council of Europe, is the most frequent tumour in women,
causing about a quarter of female deaths in the age range 35 to 54, but which can be detected at an
early stage using several methods. A general practitioner, or a patient, who is well trained can detect
manually tumours as small as 10 millimetres in diameter. More than three-quarters of these are benign
nodules, and when they are malignant, they are more easily treated.
0) M. Hakama, J. Chamberlain, N. E. Day, A. B. Miller, P. C. Prorok, Evaluation of screening programmes for
gynaecological cancer, British Journal of Cancer, No 52, pp. 669—73, 1985.
26. 2. 87 Official Journal of the European Communities No C 50/31
As regards medical imaging techniques, there are contrasting results. Thermography and ultrasound
have been somewhat disappointing in the sense that they are not much better than a well performed
palpation. By contrast, mammography has made considerable progress, not only from the point of
view of protecting patients from ionizing radiations, but also from the point of view of early
detection.
This type of radiological examination of the breast is an improvement over manual methods as it
permits the detection of nodules which are only a few millimeters in diameter. Moreover, it can
generally detect whether or not a tumour is malignant.
Studies performed in the United States, Sweden and the Netherlands, on several tens of thousands of
women followed for about 10 years, has demonstrated a reduction of about 30% in the mortality
from cancer of the breast of women over 50 years of age who were subject to mammography
examinations every two years.
In the majority of the countries of the European Community there is a lack of equipment and
specialized staff, and because of this, systematic mammography is a long-term objective in many of
these countries. In the meantime the European committee of cancer experts consider that regular
screening of the breasts should be carried out, and if possible, mammography for women who are
more than 50 years of age.
C. Cancer of the colon and rectum
These cancers are also very frequent after the age of 45 years, and are associated with high mortality
because they are often diagnosed too late. The faecal occult blood test, which can be used in principle
as a simple and cheap systematic screening test, allows the detection of precancerous lesions (25 %) or
of haemorrhaging tumours. Nevertheless, this test has not, in the past, been as useful as was first
thought. However, the recent development of improved tests offers hope for better screening
possibilities.
The digital rectal examination is another test which can easily be performed by a trained general
practitioner. This examination techique allows the detection of abnormal lumps situated in the rectum
or prostate. Finally, medical imaging techniques, colonscopy which is performed after careful
preparation of the patients, allows the walls of the rectum and colon to be examined. This long and
difficult examination is only to be recommended as a routine measure for high risk groups such as
those who have a family history of polyps.
D. Other tumours
For the majority of other tumours, in particular those of the skin (carcinomas or melanomas), and of
the upper airways, self assessment by the general public should show up any abnormal change (moles
or beauty spots which change in size or bleed, persistent alteration in the voice, abnormal lumps, etc).
In such circumstances, a consultation without delay with the general practitioner is called for.
Finally, the possibility of using recent research results relating to tumour markers, and monoclonal
antibodies which can identify specific types of cancer, offers hope for the future for the early detection
of certain tumours.
2. Actions foreseen from 1987 to 1989
Screening policies and programmes exist in many parts of the European Community, in particular for
cancer of the uterine cervix and cancer of the breast. It will be necessary, not only to promote
exchanges of information experience between these programmes, but also to carry out an up-to-date
evaluation of the available methods, taking into account the facilities and resources existing at local,
regional and national level, as well as the cost implications.
Action 31: Promotion of a policy for systematic screening and early diagnosis of cancer of the uterine
cervix and cancer of the breast
The European Commission will examine from 1987, together with the health services of the Member
States, the ways and means necessary within reasonable limits for the establishment in each Member
No C 50/32 Official Journal of the European Communities 26. 2. 87
State of a policy for the systematic detection and early diagnosis of cancer of the uterine cervix and
cancer of the breast.
For the other common cancers such as colo-rectal cancer or cancer of the prostate, the policies
followed or envisaged by the health services of the Member States are divergent, and in certain cases
their validity is still under discussion. Nevertheless, for these cancers certain populations at risk can be
identified and can be followed specifically.
Action 32: Evaluation and improvement of the policy for the systematic screening and early diagnosis
of other common cancers
Beginning in 1987, the European Commission will promote exchanges of information and experience
between Member States with a view to evaluating the efficacy of existing programmes, and aimed at
improving their efficiency.
V. EUROPEAN CODE AGAINST CANCER
Previous developments have shown that many cancers can often be avoided. If not, it can sometimes
be cured provided it is detected early enough. These general considerations must naturally be placed in
context and put across to the general public, teachers and doctors. This is a fundamental duty of the
public authorities at all levels.
At European level, however, it would be unrealistic to go into too much detail, especially as regards
food. Indeed, eating habits are an integral part of the culture of a community and vary considerably
between countries, regions or even towns.
However, the 12 high-level cancer experts who have helped the Commission to prepare this plan of
action consider that it is possible, and desirable, to draw up a few rules at European level that are
understandable and acceptable to all Europeans. It has been agreed to call this lowest common
denominator the European code against cancer. It consists of 10 simple rules. A title could also be the
'10 European commandments for cancer prevention'. At this point the wording is provisional and a
definitive text will be drawn up after the first half of 1987.
PROVISIONAL VERSION OF THE EUROPEAN CODE AGAINST CANCER
Preamble
This code is an integral part of the 1987 to 1989 action plan of the programme'Europe against cancer'
and it covers the fields of cancer prevention, information and health education of the public, training
of health care workers, and cancer research.
Cancers can be avoided
1. Do not smoke. If you are absolutely unable to stop, smoke cigarettes with a low tar content, and
do not smoke in the presence of others (x).
2. Moderate your consumption of alcoholic drinks.
3. Eat sufficient fresh fruits and vegetables.
4. Eat sufficient cereals with a high fibre content.
5. Eat low fat foods and avoid becoming overweight.
6. Avoid, as far as possible, sunburn and intense or prolonged exposure to the sun, especially for
children or if you are not used to it.
(*) For those countries where it is applicable, this commandment should be completed by 'Do not use chewing
tobacco or snuff.
26. 2. 87 Official Journal of the European Communities No C 50/33
Certain cancers can be cured if they are detected early enough.
7. Above 20 to 30 years of age, have a regular cervical smear every three to five years.
8. Check your breasts regularly, and if possible, undergo mammography above the age of 50.
9. See a doctor if you notice any bleeding or a change in the size or colour of any mole or beauty
spot.
10. See a doctor if you notice a lump or abnormal bleeding; a persistant cough or change in the
voice.
Action 33: Transformation into layman's language of the European code against cancer
In close collaboration with communication specialists, these 10 European commandments will be
transformed into a form which can be used by the media, in all the languages of the European
Community, before the end of the first half of 1987.
These commandments could, of course, be completed and changed to take account of the particular
situation in each of the countries, and of each European.
In addition, in those countries in which wine is commonly consumed, commandment number two
could be added to by an indication of the daily maximum admissible quantity.
In the same way, a doctor could modify the commandments for each of his patients. For example, for
a confirmed smoker who cannot stop smoking, he could recommend low tar cigarettes (less than
10 milligrams) and only a few (less than five a day).
Furthermore, there is nothing to stop a country going much further than indicated in the preceding
rules as concerns systematic screening and early detection. As an example, cervical smears could begin
every three years from the start of sexual activity, without waiting until the age of 20 years. It is evident
that all the previous actions, which are concerned with the promotion of better prevention by a more
systematic screening and earlier detection of cancer, should, to be effective, rely on a public that is
correctly informed and educated, and well trained health professionals.
CHAPTER 2
INFORMATION AND HEALTH EDUCATION IN THE PREVENTION OF CANCER
Two striking facts have emerged with blinding clarity and have been known to cancer specialists for
several years:
— not only can most cancers be prevented, but
— many can also be cured, provided they are detected in the early stages.
Yet, the public is largely unaware of these two incontrovertible facts. Where cancer is concerned
obscurantism is often the rule. Consequently, the 30 or so Community-recommended actions
regarding prevention, screening and early detection can only be fully effective if they are supplemented
by information and education campaigns aimed at young people and adults.
Such campaigns are carried out at more or less regular intervals in several European countries by
public or private organizations, such as national leagues and associations against cancer. European
cancer specialists unanimously believe that these useful and necessary actions should be reinforced and
extended, and supplemented by a European campaign.
No C 50/34 Official Journal of the European Communities 26. 2. 87
Needless to say European action of this type would not be a substitute for efforts deployed, or to be
deployed at national level. However, it cannot but reinforce the effectiveness of national measures by
setting itself and achieving the following three objectives:
— to make young people and adults aware that concentrating efforts, resources and experience at
European level is the best guarantee of success in the fight against cancer. The basic principles of
cancer prevention confirmed by the European committee of cancer experts should have more
power of conviction and persuasiveness with people in Europe,
— to achieve economies of scale by avoiding unnecessary and costly duplications of effort, by jointly
working out basic modules for the information and education of the public. Naturally, the basic
modules can be tailored to accommodate the diversity of national and regional cultures,
— to promote exchanges of experience between the various bodies concerned in the European
countries in order to gain the most benefit from successes and failures in the field of public
information and education.
I. INFORMING THE GENERAL PUBLIC
A European information campaign should first and foremost concentrate on cancer prevention for
this is where individuals have the widest margin for action and the chances of success appear most
promising.
The value of the anti-smoking campaign, better eating habits, the campaign against carcinogenic
agents and the provision of regular and early cancer detection facilities must be brought to the
attention of the general public. The European code aginst cancer will, of course, spearhead the
campaign. Its aim is to convince Europeans to make the necessary changes in their life-style to prevent
cancer and undergo the recommended tests and examinations to detect malign tumours in time.
To transmit this ambitious message to the general public a sustained effort spread over three years will
be needed. An analysis carried out in 1984 by the International Advertising Association (IAA) (J)
showed that in the best of circumstances the message of the major public information campaigns
conducted between 1981 and 1983 in the European Community was remembered by only:
— 15 % of the target public in the first year,
— 30 % of the target public in the second year,
— 60 % of the target public in the third year.
These figures therefore justify the principle of a multi-annual information campaign which, in the
Commission's view, should culminate in 1989 in the 'European information on cancer year' as it
concerns screening prevention and treatment. Therefore, the first step is to identify the know-how and
experience regarding public information on cancer prevention acquired at national level.
Action 34: Establishment of a directory of the private organizations against cancer in Europe
Starting in 1987, the aim is to identify the numerous private bodies which in one way and another
could contribute to the success of the 'Europe against cancer' programme (national leagues and
associations against cancer, national anti-smoking committees, etc.).
In some countries the situation is easily defined for there is a single federation, as in the Federal
Republic of Germany or the Netherlands. In other countries the situation is fragmented, as in Belgium
where there are some 30 private organizations against cancer.
The directory will also indicate the tasks undertaken by the various bodies: private financing of
research, informing the public and increasing public awareness of cancer prevention, or providing
(') European Community survey of public information campaign 1981 to 1983, carried out for the Commission
of the European Communities by the International Advertising Association in May 1984.
26. 2. 87 Official Journal of the European Communities No C 50/35
support for the afflicted and their families. With respect to the latter, it would be useful for victims of
the disease travelling in Europe to know where to turn for help in case of need.
Moreover, private organizations, already engaged in informing the public about cancer prevention
will play a decisive role in the success of the 'Europe against cancer' programme. On the one hand these
bodies sometimes possess considerable information resources in the form of monthly or quarterly
reviews, with a circulation of thousands, or even millions, on the other, they have had many years of
experience of information campaigns and increasing public awareness: many lessons may be learned
from their successes and failures.
Action 35: Comparative survey of private and public cancer prevention information campaigns
This survey will be undertaken as soon as possible in 1987.
There are indications that messages tending to stress the positive aspects of a cancer prevention rule
('stop smoking and sweeten your breath') (*) have more impact than warnings about risk factors
('smoking causes lung cancer'). The conclusions drawn from this comparative survey will, of course,
be used when designing and planning the European campaign in 1987 to 1988.
1. Actions planned in 1987
In the first year the 'Europe against cancer' programme will seek to bring cancer prevention to the
attention of the general public without, however, buying advertising space in the main media. This
means that the budget required will be minimal — an estimated 500 000 ECU.
Action 36: Bringing cancer prevention and the 'Europe against cancer' programme to the attention of
the media
At the beginning of 1987, an advertising agency with a public relations department will be selected by
public tender to bring to the attention of the media in all the Member States the European programme
against cancer.
This agency will have the specific task of ensuring broad coverage by the mass media of the following
events:
— Council meeting of the Ministers of Health on 15 May 1987 to approve the main lines of the
Community action plan 1987 to 1989,
— publication in September 1987 of a Eurobarometer poll on the attitude of Europeans to cancer and
its prevention,
— broadcasts on several European television channels of a programme for the general public on
cancer prevention in the autumn of 1987,
— organization of a large-scale meeting marking the end of the first year of the 'Europe against
cancer' programme in December 1987. Plans for 1988 and 1989 will be outlined at this
meeting.
On each occasion the European code against cancer will be distributed. It will be formulated in
layman's terms and available in the nine Community languages.
Action 37: Eurobarometter survey of Europeans' attitudes to cancer and its prevention
A survey will be carried out in March and April 1987 based on a questionnaire drawn up in close
cooperation with European cancer specialists to determine to what extent and in what respect
Europeans are concerned about cancer and its prevention.
(') The slogan 'Kiss a non-smoker and see the difference' used in some English-speaking countries is believed to
have had a considerable impact, especially among young people.
No C 50/36 Official Journal of the European Communities 26. 2. 87
The survey will be carried out by specialist institutions for the Commission in the context of the
customary Eurobarometer polls which have been carried out twice a year since 1974 using
representative samples of the population in the 12 Member States. In all, nearly 12 000 persons aged
15 and over will be questioned orally at home, in particular as regards their knowledge of the
European code against cancer.
The findings of the first survey should be available in raw form early in June and the summary report in
September 1987. Given the importance of the subject and the novelty of an international comparison
of this type, it is likely that the findings will be analysed and commented on by scientific and medical
circles, private organizations against cancer, the press, radio and television, which should facilitate
the wide dissemination of cancer prevention information.
Members of the European committee of cancer experts, and the representatives of national leagues
and associations against cancer could also help to spread the message and give it more impact by
taking part in press conferences held when the findings of the Eurobarometer survey are
published.
Action 38: Financial contribution to television cancer prevention broadcasts for the general
public
The European Community will partly finance a European television programme on the subject of
'life-style and cancer' which should be broadcast on several European television channels in the
autumn of 1987.
A television broadcast for the general public is the most effective way of getting the message of cancer
prevention across to European citizens. In particular, it will demonstrate in a calm and agreeable
manner that the great diversity in eating habits and life-styles in Europe — national and regional — is
matched by a similar diversity in cancer frequency rates.
In addition, to give more weight to the diversity of national cultures, it is proposed to use an approach
similar to that adopted in 1986 for the 'Origins of Man' programme. It started with a common plan
worked out by the eight countries involved together with a core of identical images and the final
editing took place in the BBC studios in London with presenters from the participating countries, thus
resolving any language problems while respecting cultural differences. This approach, which achieves
substantial savings, is favoured by the Commission.
Action 39: Dissemination of the European code against cancer at sports and cultural events sponsored
by the European Community
Starting in 1987, the Commission will ensure that actions within its usual information policy field will
serve to promote the dissemination of the European code against cancer.
Sports events with a distinctly European character, such as the European Community 'Tour de
l'avenir' cycle race, provide one of the most propitious occasions for communicating cancer
prevention messages to the general public. Sport and cancer prevention is not only one of the most
relevant messages — all sportsmen of note observe at least the first three European commandments:
don't smoke, limit your alcohol consumption, avoid being overweight — it is also particularly
persuasive for young people.
Special concerts to be given in 1987 in several European cities to celebrate the 30th anniversary of the
Treaty of Rome will provide an opportunity to inform the public about the programme 'Europe
against cancer'. Money collected on these occasions will be donated essentially to other cancer
prevention organizations.
Action 40: Public meeting to mark the end of the first year of the 'Europe against cancer'
programme
In December 1987 — if possible at the same time as the Heads of State and Government are meeting as
the European Council in Copenhagen — a public meeting characterized by a certain solemnity will
mark the first anniversary of the 'Europe against cancer' programme, and will serve as an occasion to
announce officially the actions planned for 1988 and 1989.
26. 2. 87 Official Journal of the European Communities No C 50/37
Action 41: Preparation of the actions to be carried out in 1989, 'European information on cancer
year'
In the second half of 1987, the Commission will begin to prepare the actions to be carried out as from
1988, concentrating mainly on the information campaign for 1989, 'European information on cancer
year' in screening, prevention and treatment. This preparation will be carried out in conjunction with
an advertising and public relations agency in close collaboration with private cancer prevention
organizations and will aslo make use of the 20 or so Commission press and information offices
scattered throughout the Community of Twelve.
2. Proposals for action in 1988
As a result of the actions carried out in 1987, European public opinion will no doubt have been made
aware on at least three or four occasions by the media of the European code against cancer. However,
if the professionals in the communications field are to be believed, fewer than one-sixth of Europeans
will have retained its message of prevention.
To strengthen the results achieved and extend them to 30 % of the public, the information campaign
launched in 1987 would have to be stepped up and widened in its scope in 1988. Basing itself on
recommendations from both media and cancer specialists, the Commission recommends that in 1988
a 'European cancer prevention week' be organized, during which the 10 European prevention
commandments would be disseminated by all possible means, including the purchase of newspaper,
radio and television advertising space. This trial would, of course, help to improve the 1989
campaign.
On the basis of the assessments provided by the aforementioned study carried out by the International
Advertising Association (IAA), taking account of the fact that it should prove possible to negotiate
preferential terms and in view of the special interest of the message to be disseminated, the cost of this
multimedia European campaign should not exceed 7 million ECU. To this sum must, of course, be
added the cost of subsidiary actions related to this European week, which are likely to amount to some
1,5 million ECU.
Proposed action 42: Organization of a European week against cancer which will serve as a test for the
1989 campaign for the European information on cancer year
This European week, which could be held at the beginning of June or September, will be the
high-point of the 1988 cancer prevention campaign.
Advertising space in the press and on radio and television will be bought and the advertising and public
relations agency assisting the Commission will put into media form the messages illustrating each of
the 10 European commandments. It will, of course, be possible for these to be tailored to their target
groups.
This media campaign will be accompanied by a public relations campaign involving radio and
television broadcasts - if possible, on a Eurovision scale - and leading articles and reports on events
related to European cancer prevention week.
The public and private organizations involved in the fight against cancer will be closely associated
with the preparation and implementation of this action week. Furthermore, such private
organizations may decide to use this occasion to launch fund-raising campaigns, if that is their
purpose.
Finally, it goes without saying that, to achieve its full impact, this European week will be accompanied
throughout the year by a variety of actions aimed at informing the public and increasing public
awareness of the fight against cancer.
Proposed action 43: Increase in 1988 of the campaigns carried out in 1987 to inform the public and
increase public awareness of the campaign against cancer
In the interest of both continuity and effectiveness, the campaigns carried out in 1987 should be
repeated in 1988, if necessary in an amended and improved form. For example:
— Eurobarometer polls will be carried out in March and April, and in September and October of
1988 to assess the impact of the campaigns carried out in 1987 and 1988,
No C 50/38 Official Journal of the European Communities 26. 2. 87
— a Eurobarometer poll on the attitudes of general practitioners to cancer, its prevention and
treatment will supplement, in March and April of 1988, the Eurobarometer poll carried out in
1987. Its findings, which will be widely disseminated in the medical press, will make it possible to
specify the strategy to be followed in training family doctors (see Chapter 3),
— financial aid will be allocated for European television broadcasts,
— the European code against cancer will be disseminated at cultural and sports events sponsored by
the European Community,
— at the end of 1988 a major public meeting will announce the opening of European information on
cancer year, in screening, prevention and treatment.
3. Proposals regarding the European information on cancer year (1989)
Launched in 1987 and consolidated in 1988, the European cancer prevention campaign should
culminate in 1989 in a European information on cancer year. This suggestion by the European cancer
experts committee was endorsed by the Commission in July 1986 and the principle was accepted at the
European Council held in December 1986 in London. The main thrust of this action should be decided
by the Health Ministers of the European Community meeting within the Council in May 1987. The
cost of this year should not exceed 12,5 million ECU.
The actions to be carried out in 1989 would, of course, draw their inspiration from what has been
done - and what has been successful - in 1987 and 1988 by way of making the public directly aware
of the fight against cancer. They would also be supplemented by actions aimed at the health
professions and teachers who will be able to pass on the cancer prevention message to young people
and adults.
Proposed action 44: Interesting teachers and the health professions in dissemination of the European
cancer prevention commandments
Such an action will have been largely prepared in 1987 and 1988 under the 'health education' section
and the 'training of medical staff section of the 'Europe against cancer' programme (see below).
To involve these key persons in a coherent and effective cancer prevention strategy, the following
could be used: publication of clear and accessible newsletters, dissemination of small posters on the
European code against cancer, making available attractive and effective teaching materials, etc.
Proposed action 45: Organization of a media campaign aimed at the general public: 12 nations,
12 days of action against cancer
This action would repeat - in an improved form - the 1988 European week. Its final programme
will be drawn up and implemented with the help of the advertising and public relations agency which
will assist the Commission in close collaboration with the public and private organizations involved in
the fight against cancer.
Proposed action 46: Intensification in 1989 of the campaigns carried out in 1987 and 1988 to inform
the public and increase public awareness of the fight against cancer
The experience gained in 1987 and 1988 will be used during the European information on cancer year
to develop and complete the work with the media and the general public started in the previous two
years.
II. HEALTH EDUCATION
Informing and arousing the interest of the general public is one thing, to make it change its attitudes is
another. Cancer prevention requires that quite a few habits acquired through personal experience or
26. 2. 87 Official Journal of the European Communities No C 50/39
cultural tradition be changed if not given up. Obviously, such changes will not come about solely as a
result of the European campaign or the national campaigns carried out in 1987 and 1988. Nothing is
more difficult to change than social habits.
Requiring perserverance and tenacity, this is a long-term fight based on awareness that the later in a
person's life it starts, the less likely it is to succeed. This is why it is important to make young
Europeans aware of the danger of cancer at a very early age by means of health education courses.
Such a task is first and foremost the responsibility of teachers and their local, regional or national
supervising authority. However, the European Community could make a major contribution if it
attains the three objectives set out in the introduction to this second chapter (dissemination of the
European prevention commandments; economies of scale; exchange of experience).
Action 47: Establishment of a comparative survey of health education programmes in European
schools
In 1987 a comparative assessment will be made of the health education courses taught in European
schools, concentrating on cancer prevention.
Proposed action 48: Drawing-up of proposals to improve health education programmes in
schools
In 1988, the Commission will - on the basis of the findings of the survey referred to above - put
before the Council a proposal for a resolution aimed at improving the health education of young
Europeans.
There will also be an assessment of the available documentation and teaching material (textbooks,
software, games and video cassettes).
Proposed action 49: Provision of teaching material relating to health education
As from 1988 and, above all, in 1989, on the occasion of the European information on cancer year,
the European Community will contribute to the translation and dissemination of that teaching
material deemed to be most suitable.
Finally, with the rise of television, health education is no longer addressed only to young people, but is
accessible to adults as well. Some television networks, in the United Kingdom and the Netherlands in
rjr' particular, have a fund of experience which can be drawn upon. This is made up, on the one hand, of
programmes dealing more particularly with the European commandments on systematic screening
and early detection of common cancers and, on the other, of programmes aimed at cancer sufferers
and their families and devoted to methods of treatment, care, counselling, etc.
Proposed action SO: Contribution to the financing of television health education broadcasts on the
prevention and treatment of cancer
With effect from 1988 the Commission will encourage the televising of programmes on health
education in line with the procedures outlined in Action 38.
By means of this European information and health education campaign on cancer prevention it will be
shown that 12 countries, nine languages and at least as many different cultures can combine to form a
living community, close to the concerns of each of its members. This will provide a prime example of a
people's Europe in action.
CHAPTER 3
TRAINING OF THE HEALTH PROFESSIONS
I. TRAINING AND THE CAMPAIGN AGAINST CANCER
The health professions, whether general practitioners, specialists or nurses, have a decisive part to
play in the fight against cancer. Nevertheless, the general opinion of European oncologists is that the
present situation in Europe should be improved. On the one hand there are severe shortages of specific
No C 50/40 Official Journal of the European Communities 26. 2. 87
health care workers (nurses and specialists) in the treatment field; on the other, training programmes
for the health professions are not always well adapted to current needs, as can be seen from the
following brief review.
1. General practitioners
In the campaign against cancer, general practitioners are in the front line. The spontaneous trust
which is placed in them and their continuous contacts with their patients make family doctors a
cornerstone of any policy of prevention, of systematic check-ups and of early detection of cancer.
Their training in these different areas is therefore decisive, and it is important that they acquire, during
their studies:
— general knowledge of the diversity of cancers, of their essential characteristics, and of the most
appropriate way to deal with them: prevention, early detection, or treatment. For instance, in the
case of some tumours, it is prevention that must be stressed (for example, avoid lung cancer by not
smoking); in others (such as cancer of the uterine cervix) it is systematic screening that should be
focused upon; and finally, in yet others (such as cancer of the testis) it is treatment that is the most
important, particularly since it can be cured in the majority of cases,
— familiarity with the most common cancers that a general practitioner is likely to encounter
regularly in the course of his daily work,
— particular knowledge of the preventive measures to be recommended to their patients,
— technical know-how, just as much for the simple taking of a vaginal smear as for carrying out the
simple manual methods of early detection of certain tumours, such as palpation of the breasts or a
vaginal or rectal examination,
— adequate knowledge of the population which has a high cancer risk and techniques of systematic
screening available in the laboratory or in the hospital. Not knowing the latter would be
detrimental to the health of patients. Insufficient knowledge of the optimal conditions of use of
these techniques can be very costly for society if it means an untimely rise in prescriptions,
— general knowledge of the possibilities available for treatment and of the considerable success
already achieved in the fight against cancer. An ignorance of this type of information is the origin
of the taboo which stops a number of doctors from speaking openly to their patient about their
disease. Misinformed, the patient may well react inadequately to the situation, thus delaying
treatment and therefore risking a successful outcome.
So that the present situation can be improved, it is necessary to increase the number and quality of
teaching staff or reduce the number of students, by updating course contents and, using modern
teaching materials, particularly audio-visual techniques and dummies adapted for training in the
manual methods of systematic screening and early detection. Finally, the initial training programmes
should also take account of the fact that the family doctor is increasingly being called upon to play an
active part in the home treatment of patients with certain types of cancer.
Now is an opportune moment in time for account to be taken of these ideas, because Member States
are in the course of reviewing their national arrangements for the training of general practitioners in
response to the Directive on specific training for this group of doctors agreed by the Council of the
European Communities on 15 September 1986. This Directive requires that by 1990 at the latest,
Member States will introduce obligatory specific training in general medical practice of at least two
years duration. Such training is additional to that of the common course contained within the six years
of training which is the minimum required by the Community Directives of 1975.
2. Specialists and oncologists
Over the last two decades there have been revolutionary changes in cancer treatment techniques, in
particular the progress of chemotherapy, at the end of the 1960s, the successes of conservative surgery
from 1973 onwards and the appearance of combined treatments at the beginning of the 1970s.
26. 2. 87 Official Journal of the European Communities No C 50/41
With the latter, the use of surgery can often be reduced by an appropriate combination of the three
main treatments currently practised: surgery, chemotherapy and radiotherapy. These techniques and
their optimum combination should be known to all specialists who are called upon to treat cancer.
Through adequate mastery of these recent scientific developments, certain amputations or excisions
could be avoided, partly or wholly, by the use of chemo- and/or radiotherapy.
Besides, for certain cancers that are progressive, a surgical intervention may be counter productive and
prejudicial to the patient. In such cases recourse should be made to another type of therapeutic strategy
using chemo- or radiotherapy.
To meet this unceasing development of cancer treatment techniques, which call for a joint approach
by specialists in several disciplines, a growing number of countries are setting up cancer centres in
which health care workers are engaged in cancer therapy full-time. These oncologists have, moreover,
often received in these very cancer centres a training which, though specialized, is also
multidisciplinary, enabling them to discuss with their medical colleagues the most appropriate course
of treatment. Such an approach, which has already proved its worth in several hospitals in Europe,
should be evaluated with a view to its possible extension.
3. Nurses
Of all the health professions, it is the nurses who are the most frequently in contact with the patients.
Accordingly, they play an important part in the fight against cancer, especially in the treatment field.
Within the European Community the basic training of nurses responsible for general care is
harmonized by Community Directives of 1977 which provide for a minimum period of training of
three years.
For several years, most European countries have had to face a shortage of nurses trained in the
treatment of cancer patients, at home or in hospital. Furthermore, the delicate and dangerous
handling of some cancer treatments calls for a basic knowledge of special precautions, in the nurses'
own interest. Here, too, a special training effort is necessary, all the more so because the course
contents have to adapt to successive changes in the therapeutic field. Account must be taken also of the
special training needs of nurses specializing in the nursing of terminally ill patients.
II. PROPOSED PLAN OF ACTION 1987 to 1989
Adaptation and improvement of training for health care workers clearly require action to be taken
above all at national and regional level and even at that of the medical faculty. The European
Community also has a modest but still significant contribution to make, however, in the following
three areas: exchange of experience, student exchanges and working out the minimum contents of
course syllabuses.
The third of these is of course justified first and foremost by the need to allow the free movement of the
health professions and their freedom to settle and practice anywhere in the European Community. But
it is also relevant to point out that the setting of agreed minimum contents of courses leading to these
qualifications, helps to guarantee a minimum level of health care for the citizens of the Community,
including those who travel within the Community, either for work or for pleasure.
On all matters of course content, the Commission of the European Communities is assisted by three
advisory committees, one on the training of doctors, another on dentists and the other on nurses. Each
of these bodies has set up a working party on cancer training in order to aid the Commission in
preparing and implementing the 1987 to 1989 plan of action outlined above.
1. Minimum content of university training programmes
There is considerable variation between European countries and sometimes even between regions
within the same country, as regards training in cancer. Some countries have made — or are about to
No C 50/42 Official Journal of the European Communities 26. 2. 87
make — major efforts to adopt a systematic and integrated approach to cancer education from the
start of medical studies. To this end they have set up chairs of oncology. In this system particular
emphasis is placed on the need for a multidisciplinary approach.
In other countries, training in the fight against cancer is fragmented and dispersed throughout the
medical course, sometimes without adequate coordination. In the general opinion of European
oncologists, such a situation is no longer appropriate, but this point of view is not yet appreciated or
shared by all teachers or doctors. There is therefore a need for a comparative study of existing training
systems.
Action 51: Comparative study of the systems of university training for health care workers
Starting in 1987, the Commission of the European Communities will be arranging for comparative
studies on the cancer instruction given at each level of medical education: basic medical studies,
specific training of general practitioners, specialists, oncologists and nurses.
The experts, who have been chosen by the working parties on cancer training (1), will submit their
reports in the autumn of 1987 for examination by the advisory committees. These comparative studies
will serve as a basis for a possible European Community action on minimum contents of training
courses in cancer. To this end, the experts appointed to carry out a comparative study of existing
training systems will examine the likely difficulties of implementing recommendations drawn up in
1986 by the committee of oncologists which has been set up at the Commission of the European
Communities:
'Students': there ought to be an oncology chair at all medical training centres in the Member States,
offering a wide-ranging course extending from epidemiology and the principles of prevention to early
detection, treatment and terminal care. The course should consist of at least 30 hours of instruction
and should be centred on the 10 principal tumour sites. An oncology examination should be set in all
courses at medical schools.
'General practitioners': these constitute a priority group in cancer education. In addition, they should
take part in a continuous training programme for general practitioners in which they should actively
participate. A periodical letter or newssheet should be considered at the national level.
'Oncologists': every Member State should recognize the specialist nature of oncology (2). The training
of cancer specialists should be harmonized among the Member States. Particular attention has to be
paid to the training and recognition of specialists with an overriding interest in specific types of cancer.
A Community training and continuous education programme on oncology must be organized, and
encouragement must be given to initiatives to prepare courses of study for oncologists.
At all events, the recent developments which have revolutionized, and still are revolutionizing, the
whole of the oncology scene from prevention to treatment, will also change the role of health care
workers in the fight against cancer. The education systems will therefore have to be adapted
accordingly. The following broad lines can already be made out:
— basic medical studies will have to enable students to acquire a better understanding of recent
changes and to be better informed and trained,
— the initial training of general practitioners will have to enable them to face up to the demands of an
increasingly well-informed public which wants more and more to benefit from systematic
check-ups and early detection of cancer and which aspires to a competent medical follow-up after
it has undergone specialist treatment,
— the initial training of specialists, including oncologists, will have to give them a better command of
combined treatment techniques and conservative surgery in the patient's own interest.
(!) Prbfessor de Moura (Portugal), for basic medical training; Professor Larra (France), for the initial training of
GPs; Dr Costa (Italy), for the training of oncologists; Dr Lister (United Kingdom) for the training of other
specialists and for the summary report.
(2) This speciality has three categories: medical oncology (notably chemotherapy), radiotherapy, surgical
oncology.
26. 2. 87 Official Journal of the European Communities No C 50/43
It goes without saying that the Advisory Committee on Medical Training and the experts responsible
for preparing the comparative study of existing training systems will have to examine the likely
difficulties of implementing these different recommendations in order to test the ground for
Community action in this field.
Also in 1987, the Advisory Committee on Training in Nursing, with the assistance of a working party
on cancer training for nurses, will adopt a similar approach. The Advisory Committee on the Training
of Dental Practitioners will also be consulted in 1987.
Proposed action 52: Formulation of proposals for improving the organization of studies in the cancer
field (initial training, general practitioners, specialists, oncologists and nurses).
In 1988 and 1989 the European Commission will, if necessary, submit to the Council proposals for
improving existing training in cancer for health care workers, on the basis of the conclusions from
previous work, after consulting the advisory committees.
2. Student mobility
In the opinion of the European oncologists, it would be desirable for European students to be able to
undertake part of their initial cancer studies in another European Community country, especially one
of those with the appropriate experience and infrastructure. An action to promote this will naturally
find its place in the Erasmus programme which could give grants averaging 2 000 ECU for six to nine
months of approved study at a university in another Member State.
In addition, to help specialist students to acquire the multidisciplinary state of mind required for good
cancer treatment, they should have an opportunity to go on practical training courses in hospitals in
other disciplines; in the same way, certain students should be offered the chance to undergo training in
firms specializing in the various types of equipment and medicinal products used in the treatment of
cancer (manufacturers of surgical equipment or radiotherapy apparatus, pharmaceutical
laboratories).
Opportunities of this kind can already be created in the framework of the European Community's
Comet programme. This awards grants averaging -4 000 ECU annually to students wishing to do
practical training in a firm in another Community country.
Action 53: Stimulation of mobility of medical and nursing students
Starting in 1987, Comett grants will be awarded to oncology students to enable them to undergo
practical training in a specialist firm based in another Community country. As soon as it is adopted by
the Council, the Erasmus programme will also be open to medical students and student nurses
carrying out a period of oncology study in another country of the European Community, provided
that this period of study is fully recognized by the home-university.
3. joint preparation and exchange of teaching materials
In the opinion of the working party on cancer training for doctors, owing to the newness of the
programmes of education and training in cancer and the rate of change in this field, the audiovisual
aids used are often the products of individual initiative and deserve to be made more widely available
and placed at the disposal of other medical faculties. In addition, in order to teach future general
practitioners the manual methods of early detection of certain cancers (palpation of the breasts or
vaginal or rectal examination), suitable models with common characteristics should be made
available. In these two areas, the European Community will be able to promote exchanges of
experience.
No C 50/44 Official Journal of the European Communities 26. 2. 87
Proposed action 54: Joint preparation and exchange of teaching materials and testing of this during
the European information on cancer year
From 1987 onwards, on the basis of the recommendations of the working party on cancer training the
Commission will promote the exchange of experience in the field of teaching materials in 1989, on the
occasion of the European information on cancer year, certain equipment developed in faculties of
medicine will be made available for testing.
4. Exchange of experience on continuous training
Continous training in the fight against cancer is of fundamental importance to all categories of health
care workers. This is a need which is well appreciated above all by those who have received initial,
elementary or advanced training in oncology. But there are plenty of family doctors and district nurses
who have never received any basic training in oncology in the course of their studies. The crucial
problem is to motivate these health care workers, especially the older ones, so that they obtain the
basic knowledge they lack and to update it regularly throughout their working lives. This task will of
course be easier if the teaching materials used are simple, attractive and appropriate to the needs of
these categories of health workers. Here, too, the European Community will be able to make a useful
contribution by promoting the exchange of experience. In addition, existing practices will be
evaluated with a view to their adaptation in other Member States, especially those to do with:
— the regular information of general practitioners. In France, for example, since 1986, this is already
carried out by means of an information bulletin, accessible by videotext; the information is
selected and put into shape by a committee of oncologists with the help of medical
journalists,
— the continuous training of oncologists at the European School of Oncology in Milan and the
European School of Haematology in Paris.
Action 55: Exchange of experience on continuous training
Starting in 1987, the Commission will promote the exchange of experience in the area of continuous
training in cancer, in particular by way of aid to the translation and dissemination of adequate
teaching materials.
In addition, resulting from the information revolution, within the European Community several
teams are working at perfecting 'expert systems'. Today programmes are being developed, aimed at
assisting decision making, by specialists in one speciality—oncology, in the present case—working in
close collaboration with a group of top-level information specialists. The object of this exercise is to
transfer the available knowledge in oncology to a programme with which the user can have a dialogue,
either to improve his training, or to permit the selection of the most appropriate diagnosis or
treatment.
Proposed action 56: Development of common computer programmes for expert medical systems for
cancer
Within the context of the research programmes, in particular the biotechnology programme (1986 to
1989), the European Commission will cofinance certain projects dealing with the development of
common expert systems in the field of oncology.
CHAPTER 4
CANCER RESEARCH
Cancer patients are now beginning to be aware that they are not condemned without reprieve. They
know that their chances of surviving longer are genuine and increasing year by year, and they rightly
attribute this to the progess that has been made in medical research. Thanks to this progress it is now
possible to save almost half of the patients, compared with a quarter 30 years ago. These are, of
26. 2. 87 Official Journal of the European Communities No C 50/45
course, general figures, since the prognoses of development of a cancer varies considerably: though
extremely gloomy for some tumours, such as that of the pancreas, it is most favourable for other
cancers, such as those of the skin.
Moreover, most experts consider that by the year 2000 it should be possible to reduce the cancer
mortality rate in Europe by another 1 5 % , even if the prevention policy advocated above is
implemented only to a very small extent. That is a good indication of the value, but also the limits, of
these measures, which have to be complemented too by a vigorous revival of research.
The practical achievements of research in Europe do not come up to the level of the ideas and
conceptions which have emerged from its laboratories. It is a paradox, though, that the majority of
anti-cancer substances produced by biotechnological processes today are made by American
laboratories, when one of these revolutionary manufacturing processes — cellular fusion — was
discovered in France by Georges Barski, and applied in England to monoclonal antibodies by Kohler
and Milstein, who were awarded the Nobel Prize in 1984. Perhaps we have an initial explanation of
this disparity if we compare the financial resources employed on each side of the Atlantic.
It is, admittedly, not easy to draw up a balance-sheet of the financial support given to cancer research
by Europe, since account has to be taken both of national and Community programmes and research
activities which are not directly connected with cancer but which contribute indirectly to the solution
of the problem.
However, we can roughly estimate the respective scale of funds allocated if we compare the financing
of the whole of medical research: 5 000 million dollars per year for the National Institute of Health in
the United States as against 1 500 million dollars per year in the Europe of Twelve. Besides that, since
cancer research has been the subject of a major American national programme since 1971, it can be
conluded that the difference in this particular field is even greater than is indicated by the overall
figures.
Over the next three years, European cancer research will receive financial support in the following
framework:
— the proposal for a fourth programme to coordinate medical research (1987 to 1989), submitted to
the Council at the end of 1986, which the Commission proposes should be allocated 37 million
ECU, including 11 million ECU for cancer research,
— the fourth programme of medical research in the industries of the ECSC (1982 to 1987) was
allocated 9 million ECU of which 1 million was for cancer; and the proposed fifth programme
(1988 to 1991) which will be sent to the Council in 1987. This could cover 12 million ECU,
including some 3 million ECU for cancer according to the present assumptions of the
Commission,
— the proposal for a first programme of research in the field of predictive medicine (1987 to 1989),
which will be submitted to the Council at the beginning of 1987,
— the programme of research in the field of radiation protection (1985 to 1989), allocated 58 million
ECU to cover the whole period, 5 million ECU of which could be assigned to cancer research in
1987 to 1989,
— the programme of research in the field of biotechnology (1986 to 1989), allocated 55 million ECU,
including 4 million ECU in connection with cancer research (1987 to 1989),
— the programme of research into the environment (1982 to 1990), which was allocated 55 million
ECU, about 1 million ECU of which concerns cancer.
In reality, the total amount committed to research is considerably higher; in the case of joint financing
the total sum corresponds to at least double, in the case of coordination it may be up to 30 times
more. Overall, the Community research projects on cancer will coordinate work covering more than
300 million ECU from 1987 to 1989.
If financing were the only reason why Europe is lagging behind, the remedy would be easy to define if
not to apply. But Europe's backwardness results chiefly from structural causes, in particular from the
No C 50/46 Official Journal of the European Communities 26. 2. 87
fragmentation of the national programmes and from the ensuing inadvertant duplications of effort, at
a time when both human and financial resources are limited. The pooling of these resources by way of
European cooperative projects is obviously a response which is as necessary as it is appropriate.
What has to be done in the first instance is to ensure technology transfer between laboratories in
different countries, in order to give the initial stimulus to lasting international collaboration and to
integrate the best European laboratories in a cancer research network. The object is therefore to create
a sort of institute without walls which will lead to a true European cancer research area. For this
reason, the measure which is one of the most urgently required is that of increasing the mobility of
cancer research workers in Europe.
Proposed action 57: European grants to encourage the mobility of cancer research workers
In the framework of the proposal for a medical research programme (1987 to 1989) which it
submitted to the Council at the end of 1986, the Commission of the European Communities
recommends that every year study grants averaging 20 000 ECU per annum should be awarded to 50
research workers for their cancer research training at a laboratory in another country of the European
Community.
By promoting the movement of men and ideas among European laboratories in this way, the
European Community will promote the transfer of scientific and technological information at the
university and industrial levels. At the same time it will create a European state of mind which will help
to make Europe more than just an economic entity and so will slow down the 'brain drain' to the
United States. Links will at last be forged between the European laboratories, which is one of the
prerequisites for setting up a network of further lasting cooperative ventures in all areas of cancer
research.
I. RESEARCH TO IMPROVE THE PREVENTION, SCREENING AND DETECTION OF CANCER
A. Improvement of information systems regarding the frequency and nature of cancers
One cannot have good quality cancer research without a suitable information system. The prevention
programme in the United States was originally based on the Connecticut cancer registry which has
undertaken the gathering of cancer information from 1985 onwards. The first register in Europe was
set up in Denmark in 1943, and that has enabled this country to have an exceptional knowledge of
cancer trends since the Second World War.
Today in the European Community there are cancer registers at several levels. Some concern a town,
others cover a region and still others collect data at national level. This great diversity makes it difficult
to compare data and make use of them, and registers on a national scale do not exist in most European
countries. In France, for example, there are cancer registers in only four out of the 100
departments in that country (Doubs, Calvados, Isere and Bas Rhin).
Epidemiology at the European level presupposes harmonized recording of all cases of cancer in the
Community.
It is, therefore, necessary to establish a basis of regulations allowing researchers in the Member States
to carry out epidemiology studies using cancer records. The legislative restrictions on keeping such
records should therefore be reduced so as not to hinder epidemiological research. Also, in certain
European countries, work on occupational cancers has had to be interrupted owing to the rules of
confidentiality in force which prohibit all prospective studies in this field. These rules must be adapted
whilst preserving the strictly confidential nature of medical information.
Action 58: Comparison of existing cancer registers and recommendations for their minimum contents
and conditions of access to them
In 1986 the Commission of the European Communities sent a questionnaire to every cancer registry in
the Member States with a view to carrying out a comparative analysis. The results will be studied in
26. 2. 87 Official Journal of the European Communities No C 50/47
1987 in order to be able to determine the scope of the data gathered and make it possible to improve
their comparability and reliability. In addition, a feasibility study will be started in 1987 with a view to
setting up a European network of cancer registers in order to create a European database on the
prevalence of cancers.
Lastly, in 1988 a conference will be held on improving the system of recording cancer data, in
collaboration with the International Agency for Research on Cancer (IARC) and the International
Agency for Cancer Registries. If necessary, proposals aiming at harmonizing the data gathered could
be established.
B. Epidemiological research to improve prevention
Preventive measures have to be based on epidemiological research, i. e. on the circumstances
surrounding the appearance of the disease according to the characteristics of the individual and of his
environment. The items of information which can be extracted permit the detection of possible causes,
the follow-up of trends in the development of pathology, and the planning and evaluation of the effect
of intervention.
European cooperation would have the advantage of access to a more numerous population, which
would increase the validity of its conclusions, especially for the least common tumours. It would also
permit comparisons between groups of people whose standard of living is similar but whose social and
eating habits vary quite considerably between northern and southern Europe.
Proposed action 59: Launching European coordination of medical research on food and cancer
This is the area in which epidemiological data are the most uncertain, as is shown by the width of the
range of estimates of Doll and Peto, according to whom 10 to 70% of cancer deaths are
food-related.
In 1987 a synthesis carried out in collaboration with the International Agency for Research on Cancer
(IARC) will be completed, in order to determine the current level of epidemiological knowledge so as
to identify research priorities and compare and harmonize methods.
This orientation phase should make it possible to bring to fruition the efforts on particular aspects of
the relationships between food and cancer. A certain number of priority themes have already been
identified, in particular the role of food in atrophic gastritis (the preliminary phase of the development
of stomach cancer) and the role played by the consumption of food fibre and other food factors in
connection with cancer of the colon. Close attention must equally be given to nutritional factors
insufficiently studied up to now but for which preliminary findings exist to a variable degree, as has
been explained in the section on prevention: fats (especially in post-menopausal women), vitamins,
mineral elements, nitrites, etc.
Proposed action 60: Stepping-up of European research on occupational cancers
Since the early 1950s lung cancer among workers in the iron mines and certain cancers among workers
in the steel industry have attracted the attention of researchers. Despite the reduction in these activities
over the last decade, the number of exposed workers in the coal and steel industries is still of the order
of two million. The Fourth ECSC programme (1982 to 1987) has stepped up work on lung cancer
among welders and on cancers affecting colliery and coking-plant workers. The Fifth ECSC
programme (1987 to 1991) is going to extend this cofinanced research on lung cancer by work on the
identification of the underlying carcinogens.
For its part, the Commission programme on the environment (1982 to 1990) will provide support for
work on the carcinogenic effects of asbestos and other materials such as glass fibre.
Lastly, for the first time since it was launched in 1978, the medical research programme provides for
the evaluation of epidemiological methods applicable to cancer-linked occupational hazards, starting
from a critical study of results published in other countries. In particular, it is advisable to draw on
No C 50/48 Official Journal of the European Communities 26. 2. 87
methodological information from research carried out in Canada at 15 industrial sites and on
exposure to 200 chemical substances.
Action 61: Continuation of the cofinancing by the European Community of research on the
prevention of radiation-induced cancers
Under the radiation protection programme (1985 to 1989), work is to be completed on retrospective
epidemiological surveys on persons who have been given radio-elements emitting alpha particles. An
example is Thorotrast (thorium oxide based), used between 1929 and 1950 as a radiographic contrast
agent for blood vessels and which is responsible for tumors of the liver. Similar research is in progress
on radium-224 which was formerly used in the treatment of certain inflammations of the vertebrae
(spondylitis) and which is responsible for bone cancers.
However, the overriding preoccupation at present concerns the effect of low radiation doses, whether
from the use of radioelements for medical purposes, natural environmental radiation or accidental
radioactive pollution.
Exposure to natural radiation comes under this heading. Radon, a radioactive rare gas resulting from
the disintegration of radium, may sometimes occur in abnormally high quantities in certain locations,
by virtue of the geology (granitic rocks) and the type of construction (impervious premises). A
feasibility study should be carried out to examine the possibility that it may play a role in the incidence
of pulmonary tumours.
The recent accident at Chernobyl has revived interest in epidemiological research in this field.
However, we must not pin too much hope on epidemiological research alone as a means of tackling the
problem of the effects of low doses. Working from theoretical calculations on carcinogenicity through
irradiation and extrapolating from data on heavy irradiation, it is indeed possible to advance the
theory that, over 20 years, the number of additional recorded cases of cancer attributable to this
accident (in the Community of Twelve) could be between 1 000 and 3 000. At first sight, this would
appear to be an appreciable figure. However, the realization that, over the same period, this
population of 370 million inhabitants will be affected by more than 70 million cases of cancer serves to
put the phenomenon into proportion. This example is a good illustration of the difficulties inherent in
assessing the effects of low doses of ionizing radiations.
Action 62: Continuation of cofinancing by the European Community of research on carcinogenic
factors in the environment
From 1987 to 1989, in the context of the research programme on the environment (1982 to 1990)
work will be aimed at rapidly detecting carcinogenic substances among the innumerable pollutants in
the environment. The work covers improved detection of mutagenicity in microbial cultures, of the
mutagenicity of suspect substances and the development of chromosome deterioration tests. All
these phenomena are potentially carcinogenic.
Proposed action 63: Launching of European coordination of medical research on cancer and
reproduction
Since 1978, European registration of congenital diseases in the newborn has made it possible to collate
statistics and carry out enquiries into birth defects. During 1987 to 1989 attempts will be made to
establish relationships with the later development of cancers in children suffering from congenital
diseases. The confirmation of a link between tumours and congenital abnormalities would help to
identify certain carcinogenic factors and their mechanisms of action.
Another area of research is biological monitoring of certain populations exposed to the mutagenic
effects of environmental factors, with the aim of seeing whether a significant variation can be detected
in the frequency of congenital diseases where it is possible to make a diagnosis during the first months
of life.
Proposed action 64: Launching of European coordination of medical research on passive
smoking
From 1987, the work carried out in this field will be brought together with a view to guiding future
work. Attempts will be made to devise a means for quantitative evaluation of passive smoking, which
is difficult to measure objectively. Help will be sought from the International Agency for Research on
Cancer (IARC).
26. 2. 87 Official Journal of the European Communities No C 50/49
C. Research to improve screening and diagnosis
Two fields of research will have a particular influence on the future of cancer screening: automated
tissue analysis and developments in medical scanning.
Proposed action 65: Continuation of European coordination of medical research on automated tissue
analysis
A consistant early detection policy implies an enormous number of different biological analyses:
smear reading, searches for viruses and characteristic proteins, histological examinations or
chromosome analysis for tumour diagnosis.
The existing analysis laboratory infrastructure is not adequate to meet the foreseeable growth in
demand. For instance, in the United Kingdom 3 million vaginal smear tests are performed every year
to detect cervical cancer. This is not enough, however, since a systematic examination every three
years of the population at risk implies at least a doubling of this figure. The situation is similar in the
other Europeafi countries, where it is estimated that 35 % overall of the women concerned ask to be
followed up. If all the women at risk wished to benefit from preventive medicine, then the whole
system would collapse.
And yet the observation of a preparation under a microscope means a great deal of work for a qualified
specialist, hence the idea of adding an automatic system to scan the preparation, a video camera and a
computer analysis system of the observed image has made progress, for both chromosome
examinations and more general cell study.
The automation of chromosome analysis (for example to identify translocations) is essential not only
in most leukaemias (diagnosis, prognosis, treatment) but also in many solid tumours. The
examination of tissue samples under the microscope will only reveal a small number of the dividing
cells, making manual methods very time-comsuming.
Automated cytology (study of cells) has been developing rapidly, especially for detecting cancer of the
uterine cervix at the pre-clinical stage in patients at risk. There are three prototype specialized
diagnostic machines currently on the way to being marketed in Europe (in the Netherlands, Germany
and the United Kingdom) and they should soon be available. This equipment provides an excellent
screening tool but it detects more suspected cases than true positives. There is a need, therefore, to test,
compare and validate the results and to develop similar systems for other cancers; another diagnostic
machine, more multipurpose in character, is being tested in France.
Proposed action 66: Continued European coordination of research on imaging in medicine
Since the discovery of X-rays by Wilhelm Rontgen in 1895, classical radiography has made enormous
strides thanks to the computer. From a series of examinations made from different angles, computer
image processing can build up a three-dimensional picture of the X-ray subject. This is the scanner
method (tomodensitometry) first developed in 1975 by the British engineer G. N. Hounsfield (Nobel
prize). This makes it possible to reconstitute by calculation a series of cross-sections through the
organism being examined in any plane chosen by the operator (tomography), allowing the shape and
location of a tumour to be identified extremely precisely.
The reconstitution of images in several dimensions can be based on information derived from a wide
variety of matters such as magnetic properties (nuclear magnetic resonance or NMR), the
radioactivity of short-period elements (positron emission tomography or PET) or tomoscanning with
photon-emitting elements (single photon emission tomography or SPET).
In NMR, the living organism is placed in a magnetic field which particularly affects the nuclei of
hydrogen atoms in the subject, moving them from their initial position. On returning to it, each
nucleus emits a weak electromagnetic signal which, analyzed over the whole subject, enables a spatial
reconstruction of the positions of the atoms and hence the shape of the tissues. Furthermore,
depending on the structure of the molecule in which a hydrogen atom is situated, the signal will vary
No C 50/50 Official Journal of the European Communities 26. 2. 87
and reveal information about the chemical composition of the tissue. This makes it possible to
distinguish grey matter in the brain from white. The signals emitted also depend on intermolecular
forces and the speed with which a molecule is moving, allowing measurement of temperature (thermal
excitement) and flowrates (blood flow in blood vessels, for example).
Compared with X-ray scanning, NMR can make much finer distinctions between tissues and in
particular separate tumour tissue from surrounding soft tissue (inflammation). Resolution of size is
also more accurate, so that instead of centimetre scales as in radiography it is possible to achieve
millimetre scales.
Existing NMR appliances are manufactured in small numbers and often on a prototype basis; such
equipment has yet to evolve considerably in the years ahead, and it is therefore necessary to test and
compare existing systems and improve their resolution. That is the objective which the European
Community has set for the period 1987 to 1989.
Positron emission tomography (PET) is based on a different principle: a living body is injected with
short-lived isotopes (for example, oxygen-15, nitrogen-13 or carbon-11) that emit positive electrons,
and their distribution is determined by a scanner. This technique produces pictures of exceptional
quality; here, too, the equipment used is extremely varied, consultation between users will make it
possible to compare the quality of apparatus under development.
II. RESEARCH ON CANCER THERAPY
For the general public, this is the main objective of cancer research. While acknowledging the major
importance of this aspect and the urgent need for effective treatment, it should not be overlooked that
prevention, in the short term, and an understanding of the mechanisms of carcinogenesis, in the long
run, will exert an even greater influence on public health.
A. Conventional treatments
Thanks to the development of medical imaging techniques, such a long-established method of cancer
treatment as surgery, which was practised as early as the 17th century, can now be used at a much
earlier stage in the development of a tumour and, above all, with much greater precision.Ablations or
amputations that were regarded as inevitable only a few years ago can thus now be avoided and
replaced by microsurgery which encroaches much less on the integrity of the body.
Radiotherapy developed very rapidly at the beginning of the 20th century after the discovery by
Roentgen of X-rays in 1895 and of radioactivity by Becquerel in 1896. From 1900, several hospitals
were using irradiation in therapy. The material used has evolved enormously, especially regarding its
accuracy of use and its safety, as much for the patient as for the operator.
Chemotherapy was born after the Second World War with nitrogen mustard, a derivative of the
poison gas and which had some effect in leukaemia cases. A long series of products having different
specific properties has been developed since then: Methotrexate (1948), Actinomycin D, etc., right up
to the most recent, viz. the derivatives of platinum (1976) and Ellipticin (1982).
Since the beginning of the seventies, good progress has been made by the combination of several forms
of chemotherapy and by judicious association of three main techniques: surgery, radiotherapy and
chemotherapy.
Proposed action 67: Strengthening of European coordination of medical research on control of
multicentre therapeutic trials
To test the value of an anti-cancer treatment thought to be beneficial, it is important to arrange for a
proven methodology which allows for unambiguous results to be reached. In this respect a
determinant role is played by the different therapeutic protocols which set out not only the ways in
26. 2. 87 Official Journal of the European Communities No C 50/51
which the procedures will be followed but also the importance of the dosages used. These choices are
made by a multidisciplinary team composed of a surgeon, a radiologist and a clinical pharmacologist.
Evidence shows that it is advisable to register these protocols carefully, above all when they are new, in
order to evaluate better their effectiveness. Such a control of therapeutic trials will be all the more
useful since it covers as wide a selection of diseases as possible, and in accordance with harmonized
methods of registration. The European dimension is essential in this respect.
The European Organization for Research and Treatment of Cancer (EORTC) was set up in 1962 and
is a non-profit-making body which plays a key role in the coordination and exploitation of European
research on therapeutic trials. At the end of 1985 it already had at its disposal a data bank comprising
the clinical protocols used for 30 000 patients distributed among the different anti-cancer centres and
hospitals which belong to this EORTC network; each year 5 000 new cases are registered and 5 000 to
10 000 previous cases continue to be followed up.
It was therefore logical to rely on the undisputed experience of EORTC with regard to the
experimental and clinical bases for cancer treatment. The support from the European Community
covers three topics:
— computerized network: the setting-up and the maintenance of the data-processing network
'Eurocode', which because of its low cost will allow easier access to its valuable clinical data banks
for oncologists and which must create a new spirit of communication among them,
— quality control: verification of the reliability of the transfer of data from the clinical case-notes to
the computer, as well as of the correct applications of therapeutic protocols,
— coordination: improvement of coordination between EORTC and the different national groups
active in clinical research matters, in order to consider joint actions.
B. New therapeutic issues in molecular biology and biotechnology
Moreover, as a result of the biotechnological revolution which began in the early 1970s, primarily in
the USA, a new range of anti-cancer drugs has appeared over the last few years, the modifiers of
biological responses, amongst which are Interleukin 2, which has shown some very promising results
with certain types of cancer, alpha interferon, which can cure nearly 90 % of cases of a particular type
of leukaemia ('Hairy cell' leukaemia) which previously was very difficult to combat, gamma
interferon, which seems effective against certain types of solid tumour, and another molecule, the
tumour necrosis factor (TNF). All these molecules, and many others too (lymphotoxin, necrosin, etc.)
are currently being investigated very closely and some important developments can be expected in the
next few years.
Other substances belong to the group of differentiation factors which seem to allow cancer cells to
mature, which has the effect of making them return to a non-expressive state.
Finally, monoclonal antibodies — which are highly specific for the antigen against which they are
formed — can be labelled by a radio-element, to localize a cancer at an early stage by means of a
scanner. They can also be used to modify the development of certain cancers (antibodies which either
inhibit tumour growth factors or inhibit acceptance of these growth factors by receptors). Lastly, they
can be coupled with a substance of high cellular toxicity which can destroy cancerous cells without
damaging normal cells; this is targeting of drugs.
Unfortunately, to date most of the industrial developments in the field of new biotechnological
anti-cancer drugs are not in Europe but in the USA. Medical and biotechnological research in Europe
should therefore meet this challenge, which is not only medical but also economic.
Action 68: Cofinancing of a European network of data banks for cell cultures producing monoclonal
antibodies
The European Community's biotechnology programme has undertaken to promote the estabishment
of a hybridoma collection network (to synthesize monoclonal antibodies). In March 1986 the Cerdic
(European centre for documentary research into immunoclones) was set up in Nice. This centre is the
European arm of the international organization known as the Hybridoma Data Bank (HDB).
No C 50/52 Official Journal of the European Communities 26. 2. 87
It has been set up becuase European laboratories often find it difficult to procure the living material
they need for experiments, and in particular the cell lines producing monoclonal antibodies needed for
the targeting of anti-cancer drugs. This material is available in collections some of which are well
known and some not, with the result that a data network is needed.
Action 69: Cofinancing by the European Community of research into genetic engineering and protein
engineering for the manufacture of anti-cancer drugs
Activities of this kind are being conducted under the 1986 to 1989 biotechnology programme.
Cloning consists of introducing into a culture cell the genetic code of an interesting protein so as to
make it in large quantities cheaply and without danger. The capability already exists to make certain
interferons, several interleucins, TNF and a substance of embryonic origin (Mullerian inhibiting
substance) which might be capable of arresting the development of cancer of the ovaries.
The expression of a cloned protein can in theory be effected very cheaply in a microbial cell such as the
colon bacillus (Escherichia coli). In practice there are many difficulties involved because the microbial
cells are incapable of ensuring, after transcription of the protein, certain modifications essential for its
activity (glycosylation, for example).
The aim of this aspect of the biotechnology programme is to develop in the European laboratories the
expertise which will enable them to perfect the cloning of any biological substance. The benefit for
cancer research is therefore indirect but very real.
Once the protein has been cloned it must be manufactured in large quantities. The problem also arises
for monoclonal antibodies. The biotechnology programme therefore also funds work on the
large-scale culture of animal or human cells.
Furthermore, by combining physics (X-ray diffraction), biochemistry and information technology, it
is now possible to produce a spatial representation of the structure of a protein molecule on a
computer screen. By this means a parallel can be established between the molecular structure and the
biological activity of a protein. It will also be possible to predict what change to a molecule would
increase its biochemical and biological activity. The ambitious target of protein engineering is thus to
synthesize molecules of greater performance than those occurring in nature. The application to cancer
will be through the study of the relationships between the activity of anti-cancer molecules and their
spatial structure.
Proposed action 70: Cofinancing by the European Community of research on the targeting of
cancer-killing drugs
This project will be carried out under the predictive medicine programme which the Commission will
submit to the Council in 1987.
Predictive medicine aims at warning of the risk factors affecting individuals or populations, factors
linked with their genetic constitution or with their environment. It lies upstream from preventive
medicine but for which it prepares the way. This programme mainly involves basic research, which
will be dealt with further, but it does include more applied aspects such as targeting of drugs.
The principle of targeting is simple: by coupling two molecules, a monoclonal antibody capable of
recognizing a cancer cell and adhering to it, together with a substance that is toxic for cells, it is then
possible to target a cytotoxic substance specifically to tumour cells and so destroy them without
affecting normal cells.
Developing these associations would enormously advance chemotherapy, but while the principle is
simple, its practical achievement is difficult.
Proposed action 71: Cofinancing by the European Community of research on the pharmacology of
anti-tumour substances
The biotechnology programme (1986 to 1989) supports several in vitro pharmacology toxicology
research areas, including one concerning cancer; these methods should help to speed up procedures for
research on anti-tumour substances and to cast light on the mechnisms of effective drugs that are
already known.
26. 2. 87 Official Journal of the European Communities No C 50/53
The development of in vitro pharmacology and toxicology methods has three objectives: the scientific
aim is to study the activity of molecules in a more analytical manner by isolating the effect of medicines
on a particular mechanism, which would make for a more precise approach to the relationship
between the structure and the activity of molecules; the economic aim is to develop a fast and cheap
initial screening of the activity of new molecules which it is hoped will exhibit useful pharmaceutical
properties; and the humanitarian aim is to reduce the number of animals used in pharmaceutical
experimentation.
But pre-clinical pharmacology should also be developed in vivo. In vivo study enables certain specific^
techniques, such as xenografts, to come close to clinical treatment conditions. Xenografts are grafts of
human cancerous tissue onto mice of a strain which has no immune defences ('nute') which do not
reject the graft. A tumour of human origin will then develop and be suitable for in vivo tests which are
close to the treatment conditions, owing both to the human origin of the cells and to the
pharmacokinetic behaviour of the mouse, which is not too far removed from that of man. The
possibility of a European project on this subject should be contemplated in the future.
Finally it is acknowledged that laboratories and pharmaceutical undertakings specializing in
anti-cancer products should be able to benefit from common evaluation procedures
Proposed action 72: Harmonization of testing standards for anti-cancer drugs
Subject to the Council shortly adopting the Commission's proposals on high-technology/
biotechnology drugs, there could be a common assessment procedure for the various Member States
regarding new anti-cancer drugs. This should help to speed up their practical utilization. Apart from
this aspect of speedier marketing, it will clearly be much easier for the pharmaceutical industry to
make profitable investments in the context of the large market represented by the European
Community as a whole and hence invest in less common diseases. It will also be much easier to find the
experts needed on a centralized multinational basis.
III. FUNDAMENTAL CANCER RESEARCH
Until recently nothing was known of carcinogenic viruses in man, which was all the more surprising in
that there were many such viruses in animals, for example leucoses (ganglionic tumours) in poultry,
cattle and cats, and these were known since the beginning of the century. From 1908 the Danes,
Ellerman and Bang, demonstrated the contagious nature of erythroblastic leukaemia of poultry, and
in 1917 the German, Rous, produced the first proof of the direct intervention of a filterable virus in a
chicken sarcoma (Rous's sarcoma). This fact met with so much incredulity that he had to wait 50 years
to obtain a Nobel prize!
Study of the genome of certain of these cancer-producing viruses (retroviruses) has enabled the genes
responsible for cancer to be discovered. These are viral oncogenes, which can trigger tumours once
they have been incorporated into the genome of cells in the affected animal.
These results have stimulated a reawakening of interest in research into oncogenic viruses in man.
Various recent observations have raised the question of the frequent presence of a virus in cases of
cancer. These viruses could thus either be the direct cause or a contributing factor. Examples which
can be cited are those of the more or less close relationships between cancer of the cervix/external
genital organs and the human papilloma between tumours of the lymphatic ganglions (Burkitt's
lymphoma) and the Epstein-Barr virus, between Kaposi's sarcoma and the AIDS virus, between T-cell
leukaemia /lymphoma and the HTLV 1 and 2 viruses, and between liver cancer and the hepatitis B
virus.
The discovery made in 1976 by the French researcher Dominique Stehelin (l), in collaboration with an
American team, of genes in the genome of normal animal and human cells with a coding sequence
similar to that of the oncogenes of retroviruses has led to a complete revision of the mechanisms of
carcinogenesis. In 1982 a group of American researchers, led by the Spaniard M. Barbacid (2), showed
that the activation of a human oncogene (responsible for a cancer of the bladder) was due to a
(') D. Stehelin, V. E. Varmus, J. M. Bishop and P. K. Vogt, 1976, DNA related to the transforming gene(s) of
avian sarcoma virus is present in normal avian DNA, Nature, 260, 170—73.
(2) E. P. Reddy, R. K. Reynolds, E. Santos and M. Barbacid, 1982, A point mutation responsible for the
acquisition of transforming properties by the T24 human bladder carcinoma antigen, Nature, 300,
149—52.
No C 50/54 Official Journal of the European Communities 26. 2. 87
mutation of an amino acid of an oncogene, and in 1983 the same laboratory showed that a carcinoma
of the breast in rats caused by a chemical agent had resulted from a specific mutation of an oncogene
which always appears on the same amino acid. The exploration of genetic aspects of very early cancers
must be expanded in the future.
Proposed action 73: Cofinancing by the European Community of research into the genome and
human oncogenes
This project will be proposed by the European Commission as part of the preventive medicine
programme (1987 to 1989), which will be sent to the Council at the beginning of 1987. The cellular
oncogenes have important normal functions in the regulation of cellular division and differentation. A
tumour can thus be due to disturbances of external origin, such as the addition of a viral oncogene, the
mutation of a cell oncogene, a chromosomal rupture separating an oncogene from its adjacent
regulatory system in the DNA chain, or any other disturbance to the control system of an
oncogene.
More than 25 oncogenes are now recognized, of which it is known how to identify the genetic code in
certain tumours such as leukaemias and lymphomas; this is of great practical importance since the
diagnosis may be more or less grave according to the oncogene concerned. Currently, of a series of
more than 50 000 human genes, about 350 have been sequenced, 80 of which are pathological, which
gives some sort of idea of the work still to be done before the whole of the human genome can be
known. What is at stake and the means required have been compared to what was required to put man
on the moon.
This enormous effort could almost be called routine if the new techniques (automatic sequencing)
were not playing such an important part, since the manual methods currently available are far too
slow for a task of this magnitude.
The problem of regulation of the expression of oncogenes is just as important as the inventory of the
genome, and doubtless more accessible. Numerous models can be studied, starting with the simplest
(yeasts, for example, possess several oncogenes, identified by hybridization with the corresponding
genes in mammals).
Another approach is research on genetic markers which show a correlation with certain pathological
states. Thus the HLA system, which brought the French researcher Jean Dausset the Nobel prize, is
correlated with cancer of the throat in fishermen from the Canton region. It is hoped that other
markers, like the polymorphism of restriction fragments, will be able to show yet more interesting
genetic links with cancer pathology.
Proposed action 74: Cofinancing by the European Community of research on nucleic acid probes
This action will be included in the draft programme on predictive medicine (1987 to 1989).
The practical use of the data obtained on the human genome will require the development of suitable
tools for the recognition of a particular gene: nucleic acid probes.
A probe is simply a copy of a gene that can be labelled by a radioactive element or any other system.
The probe has a very strong affinity for matching genetic information and can combine with it in a
perfectly specific manner, so as to demonstrate the presence or absence of a gene.
Systems of this kind are already operational for certain genes, but their scope has still to be extended
and they need to be made more user-friendly, since at the moment they are reserved for specialist
laboratories and cannot be used as a matter of course by clinical laboratories. They enable rapid
determination of the oncogene in a tumour cell to be made, for example, and can thus provide valuable
information in the prognosis of a possible cancer. They can also allow the detection of the genome of a
virus inside a cell, and therefore for example diagnose the presence of papilloma virus in the cells of the
cervix during pre-cancerous states.
Thus the European Community is going to be engaged in a long-term multidisciplinary research effort
which involves, amongst others, the cooperation of doctors, of biologists in nearly all the fields of
26. 2. 87 Official Journal of the European Communities No C 50/55
basic science, and of specialists in electronics and data-handling. This is the first time that such a
massive attempt at integration (multinational, multidisciplinary, multisectoral) has been made for a
joint action.
The specialists will, of course, say that some particular aspect or other deserves increased resources,
and rightly so. We have indeed noted some of these aspects above: nutrition, preclinical
pharmacology, virology, etc. This cancer research programme will not, therefore, be in a position to
fulfil all its aims in a few short years, and the effort will have to be continued beyond 1989.
CONCLUSION
If all these proposals contained in the action plan 1987 to 1989 are adopted, the programme 'Europe
against cancer' will have resulted in undoubted progress being made in the fight against cancer. It is
clear that this progress will only really begin with this three-yearly programme. This action will need
to be continued beyond 1989 so that the results can be confirmed and strengthened. It is also evident
that the actions undertaken and the results obtained will have to be kept under continuous review
throughout the three years.
Action 75: Regular evaluation of the action plan, 1987 to 1989, with the European Comittee of
Cancer Experts and establishment of an overall assessment in 1989
Regular evaluations of this plan of action, 1987 to 1989, will be carried out with the aid of the
European Committee of Cancer Experts, and an overall assessment made in 1989 with a view to its
being sent to the Council, the European Parliament and the Economic and Social Committee.
The totality of those 75 actions or proposed actions contained in this action plan 1987 to 1989 details
the European Community's contribution to the implementation of the programme 'Europe against
cancer'.
As concerns cancer prevention (actions or proposed actions 1 to 33), the Council is invited to take note
of the actions already underway or which will be undertaken as from 1987, and is requested to adopt
the proposed actions as quickly as possible after their submission in the period 1987 to 1989. This is in
line with the resolution adopted on 23 July 1986 concerning a programme of the European
Communities on prevention (J).
In the field of cancer research (actions or proposed actions 57 to 74), the Council is also invited to take
note of the actions already underway or which will be undertaken as from 1987 and is requested to
adopt as quickly as possible the proposed actions which have already been submitted (proposed
regulation concerning a fourth research programme in medicine and health) (2), or which will be
transmitted in the near future (proposal concerning a research programme in predictive
medicine).
Finally, the Council is requested to adopt as quickly as possible the attached proposal on the chapters
'information of the public' and 'training of the health professions' contained in the programme 'Europe
against cancer'.
(!) OJ No C 184, 23. 7. 1986, p. 19.
(2) Doc. COM(86) 549 final, 29. 11. 1986.


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