Breathing deeper

13 April 2010

Speaking to Public Service Review's Amy Caddick, Professor Dr J Vansteenkiste, of the European Respiratory Society, sheds light on efforts to alleviate the burden of lung cancer

It is estimated that 1.3 million deaths a year are caused by lung cancer, and the European Commission attributes 15% of all deaths across the European Union to smoking related diseases. This has been tackled in a number of ways, namely through education about the risks of smoking, health promotion, but also legislation and taxation.

In November 2009, the European Commission published a report examining how effective their smoking initiatives had been following the Council Recommendation laid down in 2002/3. It identified three important developments that had occurred: tobacco control, the smoking ban, and new legislature.

The World Health Organization's Framework Convention on Tobacco Control (FCTC), one initiative that came out of the Council Recommendation, was put in place to curtail the ever growing 'tobacco epidemic'. It was signed and ratified by 168 states in June 2009 and is one of the most widely embraced treaties. The aims of the FCTC are to not only reduce exposure to tobacco smoke, but also to educate people about the dangers of smoking. More than that, the convention lays down a set of rules for international health cooperation – a matter of great importance when combating smoking related diseases.

Measures to reduce cases of lung cancer across Europe have been varied but there have been a number of changes over the years in regards to smoking and tobacco related products. For example: banning cigarette companies from advertising.

"Sometimes this is elegantly avoided by tobacco companies sponsoring their product in a more discrete way, such as advertising it alongside other products that have the logo or the colours of a cigarette brand," Professor Vansteenkiste explains.

Ensuring that tobacco products are not advertised in a positive manner goes hand-in-hand with the ban on smoking in public places, which further deglamorises the habit. The impact of this has already been seen across Europe where the ban has been fully implemented; however, not all member states have applied it completely.

"There are inequalities across Europe in regards to the smoking ban. Countries like Ireland, Spain, Italy and France have taken the lead and imposed complete bans. Then you have the next level, countries like Belgium, for instance, where smoking is still allowed in cafés. Lagging behind is Germany, Switzerland and Austria. It's a gradual process but the idea of it is becoming more and more accepted."

But imposing bans on advertising and smoking in public places is only one part of the fight to reduce the amount of smoking related diseases. Education also plays a huge role. Vansteenkiste believes that acknowledging the advantages of not smoking rather than the disadvantages of smoking can have a more positive effect on behaviour.

"Sometimes this can be sponsored by the pharmaceutical companies who make drugs that aid in smoking cessation, but that doesn't matter as long as the message gets through that a life without tobacco is a healthier life."

The European Commission funds a number of programmes designed to educate young people about the problems that relate to tobacco consumption in a positive way, empowering them to take control of their own health and lifestyle. Help 2.0 is one, another is the Working with Communities to Reduce Health Inequalities: Protecting Young People and Children. Both programmes aim to promote healthier living without smoking.

"In Belgium," says Vansteenkiste, "we have a programme in schools for young children aged 9-12 where the dangers of smoking and the benefits of non-smoking are explained in a positive way. This is often undertaken by pulmonary societies, physicians and other health workers."

Many European countries have also raised the minimum age for purchasing tobacco related products to 18, applying fines and, in some cases, criminal charges for breeching this. This makes it more difficult for young people to start smoking.

"Another process that has been gradually introduced is the raising of taxes on tobacco products so that cigarettes and other tobacco products become more expensive," Vankeenkiste states. "There's a clear relation between pricing and smoking in young people so this is certainly a very effective measure that research shows doesn't lose impact over time."

But promotion and legislation are only one side of the coin; effective treatment programmes are just as important. Lung cancer is very dangerous with a high level of mortality – ongoing research is vital. Vansteenkiste identifies three levels of patient: those who are diagnosed early, those who have locally advanced tumours, and those in the advanced stages of the disease.

"Around half of those who are diagnosed with the disease early can be cured by surgical dissection. Progress made by combining surgical dissection with systemic treatments like chemotherapy adds another 10% to the cure rate. We try to customise chemotherapy to the tumour so that it's even more effective in treating the cancer. Five years ago they gave the same treatment to everyone across the board, no matter what stage of the disease the patient was at. Now, treatment is based on the biological pathways in the tumour."

Even in the advanced stages of the disease where the prognosis is poor, Vansteenkiste believes there have been developments.

"There is no cure rate once the lung cancer becomes metastatic, but over the last 10 years there has been an improvement in the length and quality of survival because of new systemic treatments such as chemotherapy and biological agents. If you combine these in a rational way you can give some of these patients a few years of survival with a reasonably good quality of life."

Studying the advanced stages has also yielded information about the biology of lung cancer and the pathways of the disease, Vansteenkiste says, and this has led to drug treatments that interact very specifically.

There are, however, inequalities across Europe in the way cancer is diagnosed and treated. The European Commission recently launched a European Partnership for Action Against Cancer to tackle this, which aims to ensure that all member states have an integrated cancer plan. It also strives to reduce all cases of the disease, 15% by 2020, by bringing together a coalition of resources and research that will be more effective in treating lung cancer.

"There is a lack of thoracic surgeons who are really experienced in lung cancer surgery in some countries in Europe," says Vansteenkiste. "That can be addressed by increasing and improving the quality of training programmes for new cancer doctors, surgeons, pneumonologists, oncologists and radiotherapists. The training programmes should aim to bring these disciplines closer to one another so that specialists are working together. That's a process that's ongoing."

Collaboration between different member states, organisations and experts is important to ensure new treatments, diagnostics and preventative methods evolve.

"The first step is the approval of anticancer drugs by the EMA – the European Medicine Agency. This needs to be done more quickly. Progress should be seen as progress and approved like that," Vansteenkiste says. "Europe should work towards giving more support and faster approval of new therapeutic possibility for the patient."