The cancer plan – 2003-2007

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The cancer plan was launched in 2003. It aims to reduce cancer-related mortality by 20% in the next five years. To achieve this ultimate objective, the plan defines a large set of operational goals (70), presented in six “priority chapters”.

Purpose of health policy or idea

The cancer plan was launched in 2003. It aims to reduce cancer-related mortality by 20% in the next five years. To achieve this ultimate objective, the plan defines a large set of operational goals (70), presented in six "priority chapters":

• Increase primary prevention, through a better knowledge on cancer causes, the fight against smoking, against work- and environment-related cancer and the promotion of pro-health attitudes;
• Improve screening, especially for breast, colorectal and cervical cancer, improve early detection of melanoma and better access to testing for heredity forms of cancer;
• Improve the quality of care and focus care on patients: I.-e. insure more equity in access to the best treatments, more coordination between professionals and also between home and hospital care, a better access to information for patients and more attention to patients' expectations, guarantee access to diagnostic and therapeutic innovation by expanding the number of diagnostic and therapeutic facilities and increasing funds dedicated to expensive new drugs;
• Provide more humane and more comprehensive social support structures: create mechanisms to keep cancer patients at their jobs and to increase patients' access to loans and insurance, favour home health care and possibilities for parents to stay close to hospitalised children, provide patients with psychological support.
• Adapt training of professionals, by including oncology education in the first stages of nursing and medical curricula;
• Develop research, by creating Regional cancer poles and a National Cancer Institute.

The total funding of the plan should be 640 million euros up to 2007, from which 13% are to be allocated to "prevention and screening", 21% to "care coordination and patient support", 16% to "facilities and care upgrades", 32% to "access to innovative treatments" and 18% to "Research and training".

The creation of 3,900 jobs is announced: 1,700 nursing and technical staff, 500 physicians, 400 for patient support staff and 660 for other categories.

Main points

Main objectives

The objective of the cancer plan is to reduce significatively cancer-related moratlity in the next five years, by increasing secondary prevention and access to innovative treatments. The plan also focuses on primary prevention and on reasearch to serve more long-term goals.

Type of incentives

The plan gives a lot of financial incentives (budgets) for the development of equipment, for a broader access to innovative treatments and for the development of research.

Groups affected

Patients, Health professionals, Health industries

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The systemic impact of the plan may be rather fundamental if it succeeds.

Political and economic background

In his speech of the 14th of July 2001, the French President established the fight against cancer as one of three high priorities (the two others were: the fight against road injuries and the promotion of a better insertion of disabled people in the community).

A Steering Committee on cancer was appointed in September 2002 by the Minister in charge of health to make a diagnosis about the French situation and to provide recommendations to health authorities about the best ways to reduce cancer-related mortality in France. This committee handed in its report on the 16th of January 2003, with the following conclusions about the French situation:

• First, cancer prevalence has been dramatically increasing in the last 20 years and France has the highest rate of cancer-related mortality in the European Union.
• Primary prevention, early diagnosis and screening are insufficiently developed.
• In spite of a good quality of care providing a fair survival rate to cancer patients (in comparison with other countries), inequalities in the accessibility to adequate and high quality care do exist.
• Equipments for cancer diagnosis and therapy are still insufficient.
• Access to innovative treatments (drugs and equipments) is also inequitable
• Access to psychological support and to other types of care, such as pain care and palliative care, have really improved in the last years but the demand is still growing
• Current modes of payments of medical services are not adapted to necessary evolutions of the system
• Shortages in oncology manpower are foreseeable.
• Cancer patients too often experience social difficulties in their work, in their access to insurance contracts or to bank loans for instance.
• Cancer patients are also short of information about their pathology and possible treatments.

 

Change based on an overall national health policy statement

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The Steering Committee formulated "10+1" recommendations for action to fight cancer were the following:

• Improve the epidemiological information system;
• Reinforce prevention policies, especially at the local level  with an emphasis on the reduction of  tobacco and alcohol consumption and on the promotion of appropriate diets;
• Stimulate the development of screening;
• Improve the quality of care through structural changes likely to produce a better coordination of care;
• Reform the payment of cancer treatments to public and private hospitals and to ambulatory operators;
• Increase the number of medical equipments and the funding of new drugs;
• Develop support and information to patients;
• Promote social insertion of cancer patients;
• Create the conditions for a dramatic development of research on cancer;
• Increase the number of professionals specialised in oncology.
• The eleventh recommendation called for the creation of a National Institute of Cancer (INCa), expected to stimulate and coordinate research activities, to provide high level expertise to professionals and to health authorities, to monitor and evaluate performances of cancer treatments and utilisation of new technologies, to provide public information about clinical trials, available treatments, social benefits and patients' rights and to promote the insertion of French research through Europe.

Initiators of idea/main actors

• Providers: Health providers may expect more ressources (human and financial)

• Patients, Consumers: Patients may expect better information, better care and social support

• Scientific Community: Researchers in oncolgy will get more funds. Other researchers fear ressource transfers from other fields.

• Private Sector or Industry: Health industry will benefit from fundings allocated to innovative treatments, to equipment renewal and reinforcement and to research activities

Approach of idea

The approach of the idea is described as:
amended: The cancer plan is a part of the Public Health Policy Reform engaged in 2003.

Stakeholder positions

The plan seems to be rather consensual in the public health community and among professionals involved in oncology. However, some criticisms emerged.

The most important criticism refers to the insufficiency of measures addressing the prevention of environment-related cancer. Even if these issues are voluntarily ignored in the cancer plan to be addressed in the National Environment & Health Plan adopted in 2004, detractors think that they are globally insufficiently treated. They observe that the cancer plan focuses exclusively on the modification of individual behaviour (tobacco, alcohol consumption, sun exposure) in primary prevention and argue that measures adopted in the Environment plan are insufficient to balance means addressed to modify individual behaviours and means addressed to protect people from environmental and professional exposure (according to the document presenting the Environment Plan, 7 to 20% of cancer cases could be attributable to environmental factors).

The second type of criticism refers to the unevenness between budgets allocated to prevention (13% including screening) and budgets allocated to care (69%). They insinuate that the plan is oriented to favour health industries producing medical devices and medicines.

At last, some actors criticize more operational aspects of the plan (not published). For instance, in the fight against tobacco, some actors contest criteria used to allocate budgets to centres specialised in smoking cessation visits. Some others regret that free nicotine substitutes had been distributed in Health centres to poor people by professionals generally insufficiently educated in the field of smoking cessation. This organisational failure will probably affect results of the planned assessment of this measure.

Actors and positions

Providers
Hospitals	very supportive		strongly opposed
Physicians	very supportive		strongly opposed
Other health professionals	very supportive		strongly opposed
Patients, Consumers
Patients' associations	very supportive		strongly opposed
Scientific Community
Researchers in oncology	very supportive		strongly opposed
Private Sector or Industry
Pharmaceutical industry	very supportive		strongly opposed
Other health industry	very supportive		strongly opposed

Influences in policy making and legislation

Some pieces of legislations encountered oppostion from industrial interets (for instance, the ban of vending machines distributing drinks and food in schools, finally adopted in August 2004).

Industrial lobbies can be very effective. An amendment to the Evin Act liberalizing the promotion of wine has been voted in the French Parliament on October 13, 2004 (2 months after the adoption of the Public Health Policy Act) with 102 positive votes on a total of 114 votes.

Actors and influence

Providers
Hospitals	very strong		none
Physicians	very strong		none
Other health professionals	very strong		none
Patients, Consumers
Patients' associations	very strong		none
Scientific Community
Researchers in oncology	very strong		none
Private Sector or Industry
Pharmaceutical industry	very strong		none
Other health industry	very strong		none

Positions and Influences at a glance

Adoption and implementation

The Cancer Plan was launched in 2003. It is one of the five national plans defined by the Public Health Policy Act voted the 9th of August 2004 (which was in preparation in 2003). Other plans are related to violence, addiction and risk behaviours; environment and health; quality of life of patients with chronic diseases; providing heath care to patient with scarce diseases.

Some measures announced in the Cancer plan were adopted in the Public Health Policy Act passed on August 9, 2004.

The plan also refers to measures which have been / will be adopted in other pieces of legislation, such as annual Social security funding Acts.

Monitoring and evaluation

A National Project Task Force, appointed by the Prime Minister and working under the authority of the Minister of health is in charge of the implementation of the plan: the MILC (Mission intermistérielle pour la lutte contre le cancer) was created by a decree of the 7th may 2003.

The plan implementation is detailed for each of the five next years in documents available on the MILC website.

Regional and national monitoring mechanisms have been defined. At the national level, quantitative goals were defined in 2003, known as the plan's key indicators. They were:

• To reduce by 30% the number of young smokers, by 20% the smokers in adult population and by 20% the number of alcohol-dependent adults;
• To reach a 80% participation rate for breast screening for women aged 50 to 74 and for cervical screening for women aged 25 to 69.;
• To guarantee access to "Customised care programs" for all patients;
• To insure access to information and support structure to all patients;
• In the research domain, the goal is to achieve international excellence. As intermediate goals: 10% of all patients should be included in clinical trials in reference centres and, for cancer-genomic research, tumour libraries must be develop up to 100,000 samples.

These objectives and indicators have been refined and a new list is included in the set of "100 objectives and related indicators" adopted in the Public Health Policy Act passed on August 9, 2004.

Results of evaluation

The first annual report on the implementation and other documents presented on the MILC website, completed by other information sources allow to present what has been achieved in the first  months.


Regarding primary prevention:

• Measures to reduce tobacco consumption have been adopted in the continuation of existing plans. Smoking prevalence decreased by 12% between 1999 and 2003 (no figure available to estimate the 2002-2003 change), cigarette prices have increased by 42% between January 2003 and January 2004, sales to young people under 16 is now forbidden and warning labels on cigarette packages have been reinforced. The National Institute for Prevention and Health Education (INPES) launched several campaigns and programs, such as the "hospital without tobacco" program. Funds have been allocated to local actions promoting smoking cessation. Health and Education ministries collaborate to implement public health policies in schools. The effectiveness of the reimbursement of nicotine substitutes is assessed in three regions and these products are available freely for poor people in Health centres of Health insurance funds. Utilisation of the "Tabac info service" hotline and the frequentation of smoking cessation visits have also increased in the last year.
• Efforts to reduce alcohol consumption essentially focus on information campaigns. INPES' goals are to inform about risks related to immoderate consumption of alcohol, to modify masculine representations of alcohol, to promote total abstinence during pregnancy and enhance the dialogue between patients and professionals. In 2003, TV campaigns have alerted on health risks related to abusive alcohol consumption and advertisements in press associated masculine values to a moderation of alcohol consumption "Bois moins si tu es un homme". The impact of such campaigns are always difficult to assess.
• About nutrition, the cancer plan reinforced funding and actions of the pre-existing National Nutrition and Health Plan (defined for 2001-2005). It participated in 2003 to the diffusion of "nutrition guides" for patients and professionals, to the national campaign promoting the consumption of "at least" five  fruits and vegetables per day and to the campaign promoting physical activity. According to the Public Health Policy Act of August 2004, manufacturers of drinks or food containing added sugar, salt or sugar substitutes will have to insert warnings about health risks in their promotional messages or to pay a tax (1,5% of promotion expenditures), which will be affected to INPES.
• To prevent skin cancer, campaigns have been launched to inform people about health risks related to sun exposure and the 6th "national day for free screening of skin cancer" was organized by professionals.
• Environmental aspects are not really taken into account in the cancer plan but will be addressed in the National Health & Environment Plan (2004-2008) and in the announced "Workplace Health Plan 2005-2009". The only step forward of the cancer plan to reduce professional exposure to cancer is the framework agreement signed in February 2004 between Health and Labour Ministries. It mainly aims to increase knowledge about professional exposure to carcinogenic substances and to improve cancer detection at workplace. An annual program will be established each year to define operational goals.
• Funds have been allocated to institutions and programs dedicated to research on cancer-related themes (about smoking behaviour, about environment health and about epidemiological knowledge).

Regarding screening:

• Breast cancer screening is organised everywhere since the 1st of January 2004 (except for Guyana): every woman between 50 and 74 will be invited to benefit from a free breast screening every two years. The goal is now to increase the participation rate up to 80%. Its estimated value for 2003 was 30%, with huge variations between departments (11 to 70%). Several campains at national and local level will be launched and an Observatory has been created to analyse screening activities.
• Colorectal cancer screening for people is experimented in 22 départements and will be assessed at the end of 2004 to define the national strategy.
• Cervical cancer screening is proposed to women aged 25-69. The participation rate, estimated in 5 regions is of 25% and the plan targets a 80% rate. The benefits of the Human papillomavirus test has been assessed by the French National Agency for Accreditation and Evaluation in Health (ANAES), which did not recommend its systematic use in association with the pap test.
• Funds have been allocated to oncogenetics: the number of genetic tests and of oncogenetic visits have sharply increased.

Regarding health care:

• Funds have been allocated to the development of cancer-care networks;
• The regional organisation of cancer care is changing: cancer-related activities will be submitted to authorisation (delivered by the Regional Hospitalisation Agency), hospitals will be labelled according to a hierarchy of interventions in cancer treatments as "reference centres", "specialised centres" and "participating centres".
• Cancer networks will be created at the regional level to coordinate regional operators, to share information on experiments, to pool resources and competencies. The constitution of regional poles aims at insuring at the regional level equal access to innovation and high specialised equipment, to the equity of access to complex treatments or to high specialised equipment.
• Coordination cells (Centres de coordination en Cancérologie or "3Cs") will be created in each hospital to coordinate activities of all professionals. They will elaborate customized care programs for each patient (Programme personalisé de soins or PPS). Such cells already exist in some hospitals, especially in the main Cancer centres. They have to be created in other hospitals in 2004.
• Consensus conferences on professional practices and recommendations are prepared by ANAES and some recommendations were already diffused in 2003.
• Paediatric cancer care has been re-organized in 2004: Hospital Regional Agencies identified services in charge of coordinating and providing paediatric cancer care at the regional level, while reference centres have been identified at the national level. The INCa will promote research programs to improve paediatric cancer treatments.
• Home cancer treatment should be developed through "hospital at home": ANAES published in 2003 a first set of recommendations to identify eligible patients for home chemotherapy and a second set of recommendations is in preparation to define optimal conditions for care organisation. The simplification of planning rules passed in September 2003 and new funding should increase the supply of home cancer care.
• The increase of support care is also planned. In psycho-oncology, the target is to reach one psycho-oncologist for 1500 new patients). In pain care, new services have been created, access to pain killer drugs will be easier and the National Federation of Cancer centres published recommendations for pain assessment. For palliative care, regional networks are developing and supply for home palliative care will increase. The plan aims to reduce existing geographical inequalities of access to these services.
• The creation of a dossier, containing all information about the patient is experimented in four pilot regions.
• Several strategies to announce patients that they are suffering from cancer are experimented throughout the country (37 projects).
• As planned in the "Hospital 2007" plan, equipment for cancer treatment and diagnosis will improve in the five next years to reach the European level of equipment, to renew and modernize existing equipments and to favour more equitable access to new technology in the country. Targets to 2007 are the following: to install 112 new linear accelerators (82 replacements and 40 new points of care), 69 scans and 68 MRI, to reach the level of one PET scan by region.
• A national program aims to support innovative treatments and diagnosis methods by funding specific projects.
• To improve access to innovative medicines in hospitals, budgets for very expensive treatments will be isolated in the forthcoming DRG linked hospital payment system.

Regarding social support to patients:

• The first goal of the plan is to increase knowledge of patients about the Belorgey's Convention signed in 2001 to improve access of seriously ill patients to bank loans. The terms of the convention should be further extended to pertain to more cases.
• To provide more information and support, a hotline "Cancer info service" has been created, kiosks are developing in public areas (shopping areas, etc.). Patients associations' interventions in hospitals will be promoted through formal agreements. The "Cancer plan website" was created in February 2004.

Regarding health professionals demography and education:

• Several measures have been adopted to avoid the foreseeable decline of cancer-related specialties numbers: active specialists will be qualified as "oncologists" by ad hoc commissions in the next few years; oncology will be taught in the first years of curricula to attract students in this specialty; and the numerus clauses will be increased from 140 to 210 per year for haematologists, radiotherapists and oncologists; career opportunities will be developed to make these specialities more attractive.
• The number of medical physicists should double to reach 600 and internships will be paid to make this profession more attractive.
• The profession of radiotherapy technician will be advertised in high schools to attract students.
• Cancer is considered as a prioritised  theme for continuous education of health professionals.

Regarding research:

• Cancer will be considered as a priority in the existing Clinical Research in Hospitals Programs (PHRC: Programme hospitalier de recherche clinique) . In 2003, 42% of selected projects were cancer-related, for a total amount of 12,7 millions €.
• In 2003, 7 centres have been selected to become "Canceropôles" and received funding: Île-de-France, Provence-Alpes-Côte d'Azur, Rhône-Alpes, Grand-Ouest, Nord-Ouest, Grand Sud-Ouest and Grand Est.
• A call for tender has been launched in February 2004 to fund research projects based on priority themes of the cancer plan, promoting collaboration between research teams and partnership with industry.
• The position of France in the European cancer-related research strategy is to be reinforced and French teams will be encouraged and supported to enter in the competition at the European level.
• Bilateral cooperation between France and the UK has been set up to share experiences and results of national policies.
• Last but not least, the National Cancer Institute (INCa) has been created by the Public Health Policy Act of August 9, 2003. Its President has been appointed.

 

Expected outcome

Previous public health plans already succeeded in reducing tobacco consumption and changing social norms about smoking. This is not yet the case for alcohol consumption. Healthy behaviours are actively promoted (nutrition, physical activity) but the impact of such campaigns on individual behaviours remains difficult to evaluate.

The plan is likely to increase early detection of cancer and to improve access to innovative treatments throughout the countries. The outcome in terms of survival and mortality, in terms of quality of life for patients will have to be assessed.

Coordination of care is a very important point of this plan (between institutions, between professionals, between hospital and home). Some actors seems to be rather sceptical about its chances for success, arguing that practices are always difficult to change, but this opinion is very difficult to assess.

We can hope that patients will benefit from this plan:  more equitable access to innovation and quality, more support care (pain care, palliative care), more social support. But what seems to be certain, is that health industries will benefit from it.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

Report of the steering committee on cancer  (16 January 2003): www.recherche.gouv.fr/rapport/cancer/default.htm

Website of the Cancer Plan: www.plancancer.fr/

Brochure of the cancer plan: www.plancancer.fr/Documents/PlanCanBrochure.pdf

In English: www.plancancer.fr/Documents/CANCERPLAN.pdf

First annual report of the MILC: www.plancancer.fr/Documents/RapportGeneral.pdf, www.plancancer.fr/Documents/RapportRegional.pdf

Public Health Policy Act of August 9, 2004 (legislative dossier): www.assemblee-nat.fr/12/dossiers/sante_publique.asp (You have to open the DPF file to see the table containing the 100 objectives of the Public health Policy Law)

National Nutrition & Health Program 2001-2005 (Programme National Nutrition Santé): www.sante.gouv.fr/htm/actu/34_010131.htm

National Health & Environment Plan 2004-2008 (Programme national santé environnement PNSE):  www.sante.gouv.fr/htm/dossiers/pnse/sommaire.htm

The Belorgey Convention : www.plancancer.fr/Documents/BelorgeyMiniguide.pdf

Author/s and/or contributors to this survey

Valérie PARIS

Suggested citation for this online article

Valérie PARIS. "The cancer plan – 2003-2007". Health Policy Monitor, November 2004. Available at http://www.hpm.org/survey/fr/a4/1