Colorectal Cancer Screening in Europe – is a Utopia Possible Where an Extra 80,000 Lives are Saved per Year?
At the end of last summer – August 2020 – the project ‘EU-TOPIA: Towards Improved Screening for Breast, Cervical and Colorectal Cancer in all of Europe’, came to its conclusion. The European Commission funded project ran over five years with an approximate budget of €2.9 million and conducted research into why large inequities in screening capabilities across the region still exist, despite significant progress having been made in the detection and treatment of these cancers. The project is now being followed up with a second similarly budgeted five-year project started in May this year – EU-TOPIA-EAST – that will explore screening and the local health and social systems in the Eastern countries of Georgia, Montenegro and Romania. The consortium will use key indicators coming out of the EU-TOPIA project to monitor these country’s existing programmes.
Given that 80.000 extra lives can be saved with effective colorectal cancer (CRC) screening programmes being in place in all European countries1, these projects are of utmost importance for Digestive Cancers Europe and its Members. We spoke with Iris Lansdorp-Vogelaar, Associate Professor, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, whose organisation led EU-TOPIA and is now leading EU-TOPIA-EAST, about the effects of the projects, what this means for the citizens of Europe and their health and how our Members can possibly use the country insights available.
DiCE: Iris, can you please tell us about the EU-TOPIA projects?
Iris: Yes, I’d like to first tell you about the origin of the name EU-TOPIA. It is an acronym built from TOwards imProved screening for breast, cervical and colorectal cancer In All of EUrope. Utopia is a place of ideal perfection, but as such is impossible to achieve – we see EU-TOPIA as a place of wellbeing, a practical aspiration of utopia in screening practices. So, a motivating purpose upon which to rally for the seven members of the consortium.
Working with members from six partner institutions from across Europe, the department of Public Health was very pleased to lead EU-TOPIA. Our partners were very well-respected institutions – the London School of Hygiene and Tropical Medicine in the UK, The Finnish Cancer Registry, CPO Piemonte – the regional oncology reference point in epidemiology and prevention in Piemonte, Italy, Institute of Oncology, Ljubljana, Slovenia, the National Institute for Health Development Estonia, and the Syreon Institute of Hungary.
Our work had the collective objectives of firstly conducting research on the harms and benefits of existing screening programmes for breast, cervical and CRC screening in all European countries. This included the systematic and quantified evaluation of the screening programmes, followed by identifying ways of improving health outcomes and equity for citizens. Our second objective was to provide national, regional and local policymakers with the expertise and tools to evaluate and quantify their screening programmes.
As a first phase of the project, we determined the steps of the health policy cycle (monitoring, evaluation and barrier analysis) for four exemplary countries: Finland, Slovenia, Italy and the Netherlands. In the second phase we then went on to organize interactive workshops for delegates from all 28 EU states and 11 associated countries to build capacity to conduct cancer screening evaluation independently. To make this happen the team came together face-to-face 13 times over the five years and took part in extensive exchanges producing 16 peer reviewed and one non-peer reviewed academic papers.
For EU-TOPIA EAST, it started in May this year with some of the partners from the original project including our Italian, Hungarian and Slovenian partners and our institute in the Netherlands. We were then joined by the Georgian Society of Clinical Oncology (GSCO), the Institute of Oncology (IOCN) “Prof. Dr. Ion Chiricuta” Romania and the Institute for Public Health Montenegro (IPH-MNE). Our objective here is to improve screening in the Eastern European countries, investigating and implementing roadmaps developed in the EU-TOPIA project. Here the exemplary countries of Georgia, Montenegro and Romania were chosen because of their active participation in the first EU-TOPIA project, their income status – the grant was specifically targeted to implement screening in Low- and Middle-Income Countries – and the fact that the barriers identified in these countries were representative for many countries in the region.
The project is also open to other Eastern European countries, in the form of interactive workshops, like in EU-TOPIA. Here we will educate countries on the tools developed in the project, share the experiences from the exemplary countries and participants will have a chance to exchange barriers and solutions to problems they face with their screening programmes.
DiCE: What results should European citizens await from such a research project?
Iris: We hope that our work paves the way for governments to establish robust screening programmes that can save more people’s lives. To enable this, our concrete aim is to provide researchers and policy makers access to well-established and validated simulation models that provide the basis for evaluating the long-term impact and cost-effectiveness of breast, cervical and CRC screening programmes.
Studies show that when they are executed following best practices, screening programmes save lives and valuable monetary resources. Resources that can be invested in the healthcare system in other ways – to help prevention programmes for example. We hope the governments have taken up the call and that EU-TOPIA will start having its desired effect – it will take time as it requires a holistic, multidisciplinary approach that involves complex human relationships – but governments now have roadmaps, and this is an important step forward.
DiCE: If you were to give advice to our Members, who have to advocate for proper CRC screening with local governments in their countries, what would it be?
Iris: I can only encourage them to share the facts and best practices that we have produced, and that I know DiCE is also producing, with their local policy makers. The evidence is clear that CRC screening works and is beneficial to healthcare systems.
They are also welcome to contact us through DiCE if they would like to know who, from their country, was involved in the project. It would be possible to connect with them and discuss how their organisation could best help in advocating for the recommendations that came out of the first EU-TOPIA project and in time the EU-TOPIA EAST project.
DiCE: Thank you, Iris, – we wish you all the very best for this second part of the project and we look forward to any updates you may have to share with us soon!
Below useful key excerpts on good CRC screening practice resulting from the EU-TOPIA project. We also invite you to keep an eye out for DiCE’s second CRC Screening Summit this year – set to take place in November.
“Overview of barriers to effective cervical and colorectal cancer screening programmes.
[Screening sub-system -> Key barrier]
- Generation of knowledge and effectiveness -> Delays to implementation/updates
- Identification of population at risk -> Incomplete/inaccurate/outdated population registers
- Maximisation of uptake (informed participation) -> Opportunistic screening
- Operation of the programme -> Inadequate resources
- Maximisation of follow-up -> Limited monitoring of long-term follow-up
- Assurance of effective treatment (for those that need it) -> Limited monitoring of long-term treatment”2
Important attributes of a Successful Cancer Screening Programme
“The most important attributes were having up-to-date and evidence-based guidelines, followed by mechanisms for systematic monitoring of screening uptake, having a population register covering all of the eligible population and monitoring long-term outcomes.”3
Key indicators of organized cancer screening programs: Results from a Delphi study
“We found a strong consensus among European screening experts on the key list of screening indicators.” “The top 10 indicators by study participants were interval cancer rate, detection rate, screening attendance, screening coverage, cancer incidence, cause-specific mortality, proportion of persons attending further assessment after a positive screen test result, proportion of persons attending a treatment after diagnosis, invitation coverage, and distribution of cancers by mode of detection.”4
The EU-TOPIA evaluation tool: An online modelling-based tool for informing breast, cervical, and colorectal cancer screening decisions in Europe
“For policymakers, it is essential to get an insight into cancer screening’s favourable and unfavourable short- and long-term effects.”
“Our study introduces an essential tool for helping policymakers and medical societies to inform their cancer screening decisions, combining both short-term (regular monitoring of quality-assurance performance) and long-term estimations. This tool may be crucial in quantifying future benefits and harms in Europe and making future preventive programmes accountable to citizens and clinicians.”5
This tool is available, following registration for an account, at: miscan.eu-topia.org.
1. Joint Statement – Call for Action on CRC Screening in the EU, CRC Screening Network in the EU, Thematic Network
2. E. Turnbull et al. / Health Policy 122 (2018) 1206–1211
3. Priaulx et al. A choice experiment to identify the most important elements of a successful cancer screening program according to those who research and manage such programs. Int J Health Plann Manage. 2019 Jan;34(1):e34-e45.
4. Csanadi et al., Journal Medical Screening 2019
5. Gini, Prev Med Rep. 2021